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English - 19'00''
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| 00'17'' | Case presentation
Hello I’m Dr Steve Rothenberg coming to you from the Mother and Child Presbyterian Hospital in St Luke’s in Denver. I would like to welcome you for the third in a series of three live web broadcasts which we are showing as an educational event for pediatric surgeons all over the world. Today’s broadcast is sponsored by Karl Storz Endoscopy and will feature OR1 and Network1. Today we are going to be doing a laparoscopically assisted repair on a 3-month-old with imperforate anus. It’s my great honour to introduce to you to Dr Keith Georgeson, who is Chief pediatric surgery at Alabama Children’s Hospital who has kindly donated his time to come and moderate for us. As you all know Dr Georgeson was instrumental in developing this laparoscopically assisted pull-through and as we do this today he will give us his insights through his large experience throughout this procedure. You will be able to email or ask questions during the procedure, which Dr Georgeson will evaluate. At this point I am going to turn the session over to him and go ahead and start the procedure. Thank you Steve, it’s a pleasure to be here, I thought I was coming here to instruct Steve on how to do this but I’m happy to provide whatever moderation is needed. If we can roll the cameras over to the patient, I can just describe what you see. Can we have a view of the patient on the table so they can see? |
| 01'55'' | Trocar placement
I have gone ahead and put in the trocars just to try and facilitate this since we are going to try and do this procedure within an hour. We have three trocars, we may elect to add a fourth. The centre trocar, the one right here is in the umbilicus and that is our camera port. You can see that gives us an excellent view down into the pelvis, we’ll show you that in just a minute. There are two other ports, my left hand operating port right here which I use for an atraumatic grasper, and then my right hand which is my dissector and in this case, I think that a lot of the procedure will be done with a little 3mm hook cautery to mobilize the mesentery. We will be using 3mm instruments today. This child weighs approximately 5kg and again is around 3 months old. These are short-shafted instruments. They are around 20cm in length. We have the table tilted towards me so that it is a sort of Trendelenburg position. We will start the procedure. We are going to start by making an incision into the mesentery. |
| 03'01'' | Start of procedure
Again we are very fortunate to have Dr Georgeson here who really pioneered this procedure. I am sure he has many suggestions. I am just trying to follow the fistula down, going circumferentially around the colon, trying to get down to the level of the colo-urethral fistula. On the patient’s preoperative study it looks like the fistula probably goes into the prostatic urethra which is the most common. You can see what a great view we have and how nicely this kind of dissection allows us to get into that plane. Maybe you could talk a little bit about why you decided to develop this technique as approach to using a posterior singular approach, what you thought the advantages would be. You can see that the initial approach here for the mobilization is very much similar to the laparoscopically assisted pull-through for Hirschsprung’s disease, a technique that many are comfortable with. We are going to try and find the posterior aspect of the rectum here and see if we can create a window. I currently have three ports but I wouldn’t hesitate to put in another one to get retraction if we need it. Again a lot of it, some fine dissection, some blunt dissection, trying to make sure we preserve the vessels and the nerves in this area. It’s very easy to do the peritoneal part or the intraperitoneal part of the rectal bladder neck fistulas, but there is a long distance then between the perineum and the perineal cavities, so I don’t suggest that as a good type case to start with. This patient has a urethrogram and also when they did the distal fistulogram it seems to narrow down nicely so I think it’s going to be a good case to illustrate the technique. What I find is that if you get around behind the rectum, you can identify the fistula and then you can tell where to go anteriorly. I think we are about there, you can start to see the few connections that are left are very flimsy and now we are through. The visualization is just so incredible. Hopefully we will be able to show you once we have the fistula mobilized how well you can see the levators internally. You can see now that it is starting to narrow down and again it seems to narrow from back to front, that’s one reason why it’s nice to be able to go after this lesion primarily from behind. This part of the operation is really the longest part of it and I am impressed at how nicely it is going. Right there is the pelvic floor so that you get an idea of where we are. We are using a 30° scope and now we have totally flipped it upside so it comes down into the pelvis. Occasionally what I do if it is really difficult to see is open the fistula anteriorly in that way you can see where it goes into the urethra and that’s what we always did with the posterior sagittal so its really no different but you can see right now as it is going down into the pelvis is that it’s narrowing, it seems to be going forward from the posterior aspect. Did you have a trenchant neurogenic bladder in the postoperative period? I have not seen that, we usually leave a Foley in for a day or two postoperatively, longer if I am concerned for some reason but we have not seen a problem with that. What you can see is that it never actually enters the urethra. |
| 07'44'' | Description of enema
We do have a voiding cystourethrogram which does show that there is a little fistula coming into the prostatic urethra and we don’t have that film up, it’s down at the tip. You can get a view of how you have a bulbus distal rectum that then quickly goes down into a very small fistula. Then you see right at the bottom it narrows very quickly, that’s typical of prostatic fistulae. When you have a rectal bulbar urethral fistula, it tends to be a little longer and then it has a common wall with the urethra for a longer distance. That’s one of the reasons why when you first start doing the operation it is much better to do a prostatic fistula then a bulbar fistula. Anyway you can see that this really has narrowed down and you see that he is now pulling a little of the prostatic tissue down with him there, so it is close. |
| 09'09'' | Transection of rectum
Can we use clips? Yes you can use clips, I have had one clip erode into the urethra. Dr David Joseph who is one of our pediatric urologists about that and he said that it is also described in the urology literature as well, so since that happened to me I stopped using clips. Push it down to the bottom. You look down here, you can see the levators, it is a beautiful view. There is a fistula that is ligated and here are the levators. So we are going to leave that there, now what we are going to do is go to the perineum. |
| 10'27'' | Perineal exposure
Legs are kept in the field, so what we have done is brought the legs into the field, we have left our trocars in place and you need to be aware of them, obviously it is a small baby so you could cause injury. There you can see the centre of the complex, so I am going to put a mark there and a mark there. So again these mark the centre of our anal complex and then we have the anterior and lower limits. I am just using what appears to be the midline to make an incision right down the middle. You can see the point of maximum contraction, so we’ll go ahead and stimulate and you can see we are right in the centre. So the goal here is to try and preserve all that and rather than cut this, as you can see the complex. You can really see how narrow the fistula is, that was a great shot. I am going to try and come down a little further. It is very easy to go too far anterior but that is perfect right there. I like to go in first just with the Veress needle, so now we are going back in, hopefully we’ll be in the same place. So now what we do is we use the step trocar which comes with this dilating sheet, so that it is dilated to a 5mm, next to a 10mm and I will need a 5mm Babcock hooked up. Now what is happening here is that he is putting his clamp up and the surgeon on the laparoscopic side is actually passing it to him because it is very hard to grasp something from below. So I have now grasped it and I am going to pull it into the trocar and here we see it, right there. |
| 12'41'' | Colo-anal anastomosis
So I am just going to put some stay sutures in. You can see the mucosa here. It almost looks like a normal anus. I am just going to put in a couple of stitches here so we show this to you well, I wouldn’t normally do this stitch. So we are going to go back inside for just a minute now that I have pulled this through. Have you ever done this without a protective colostomy? I have done it twice, the big problem really is determining the precise anatomy in the newborn period, we are working on how to figure that accurately but I think that this is a perfect technique to do in a newborn period without a colostomy. I haven’t done it much because I don’t have a good way of defining the anatomy preoperatively. I can tell you though that if you do decide to do that, you will probably have to make a little suprapubic incision and aspirate out the sigmoid colon, then close that and that gives you the space to work in. Now you can see that we’ve got a full thickness bowel wall. As you can see he is trimming off that redundant tissue, that a good thing. To me the most important aspect of this is to make sure that you have a full thickness wall and not just mucosa. So how many stitches will you put in? I would put in 4 more, or 6 or 8 more, I guess 8 more. The one thing I like about the hitch stitch is that the thing I have been most amazed about is that I have patients you can’t tell that they had imperforate anus. If someone looked at them, their anus looks so normal because it is a small incision and the hitch stitch that they have a normal anal dimple. You can see how everything is right in front of you, we have not divided the muscle either anteriorly or posteriorly. That is pretty much it, you can get a good view there, see how nice that looks. So we’ll start and I’ll size them in the office, I start about two weeks after the operation just to see. Now this is a number 8 and you can see that that just falls in, it does not get much better than that. We’ll go ahead and cut these sutures. So we’ll have mum do it twice a day and then I will have her come back in about 10 to 14 days and I will go up in size. For this child, I think we will not have to dilate very much. You can see that the child already starts to have an anal dimple. What we will do now is go up above and see if we need to put in a hitch stitch. Again we use two 5mm ports and a 3mm port. I use the second 5mm port primarily to get in the stitch, in this case the Endoloop. Otherwise I would not have needed it. See how nicely the mesentery still sits there. There is the ureter, we don’t want to get that. I’m thinking we’ll put it somewhere about here. So we are pulling up, you can see that is pretty taut. That’s basically the operation, what we have to do now is simply take out the trocars. I do want to show you the anus again. Despite the small amount of stools still. I want to thank you all for tuning in for what is now the third broadcast in a series of three but hopefully will be a much longer series of not only procedures from our institution, the Mother and Child hospital in Presbyterian St Luke’s in Denver, but hopefully centres all over the world where advanced pediatric laparoscopic cases are being performed. I’d like to thank again Dr Keith Georgeson for taking the time and energy to come here and be here with us for this procedure. There is no question after listening to him today that he has a vast wealth of knowledge about this procedure and the world’s biggest experience with it. We would like your feedback after this, if you think this has been a worthwhile and educational endeavour, I hope that you’ll email us and give us that feedback. There will be a questionnaire that comes to you and we are tabulating those results to decide whether or not this is something we should pursue. I think it has been very valuable, certainly for me, and hopefully it has been for you as well. Again I would like to give special thanks to Karl Storz Endoscopy who provided the educational grant to allow us to broadcast these surgeries, they have been intricate in surgical education, especially in pediatric laparoscopic surgery and we greatly appreciate their help. I’d like to thank as always my anesthesiologist Dr Clark, Lee Handy my assistant and Harris my OR coordinator for helping us put these cases together. If you have any questions or comments, then don’t hesitate to put them in, otherwise you should receive an email blast for the next time we schedule a procedure. Thank you again. |
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