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Bailez MM, Roumieu PL, Alvarez L, Martinez V, Dibenedetto VP. Rectovaginal Fistulas: Comparative Analysis of Laparoscopic Assisted Pullthrough and Posterior Sagittal Anorectoplasty. J Pediatr Surg 2024; 59:421-425. [PMID: 37989645 DOI: 10.1016/j.jpedsurg.2023.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 11/23/2023]
Abstract
AIM Compare the laparoscopic treatment (LT) and the posterior sagittal anorectoplasty treatment (ST) of the rectovaginal fistulas (RvaF) in a single center. We have previously reported feasibility and results of LT in this rare variety of anorectal malformations (ARM) [1-3]. MATERIAL AND METHODS 19 patients were treated between February 2000 and November 2020. Nine underwent a LT and 10 a ST. Both surgical techniques were previously described. [2][4][5] The distal posterior wall of the vagina was kept intact in the LT. A technical change was introduced in the ST for that purpose. The fistula was treated from the inside of the rectum, avoiding the opening of the distal vagina as described for the treatment of a urethra rectal bulbar fistula in males. Age at operation, associated anomalies, sacral ratio index (SR), complications, urinary continence, presence of spontaneous intestinal movements, constipation, soiling and requirements of bowel management program (BMP) were analyzed. RESULTS Associated anomalies occurred in 17 patients (89.5 %), 63 % of which were urological. Five (26 %) had a SR below 0.4; 4 in the LT group and 1 in the ST group. The mean age at the time of operation was 23.2 (8-59) in ST and 17.6 months (4-32) in LT. Average operative time was 190.4 min for ST (120-334) and 195.8 min (90-270) for LT (p 0.13). One patient in the LT group presented a mild rectal prolapse and 2 a partial wound dehiscence after the ST. Only 15 patients were evaluable for functional results (8 in ST and 7 in LT). Mean follow up was 83 months (12-197). All patients are clean with a bowel management program. Five of the 7 patients undergoing a LT had a bad prognosis (SR < 0,4). Three (43 %) are clean with diet or any treatment, 3 (43 %) using laxatives or enemas and 1 (14 %) with a trans anal irrigation system. Only 1 of the 8 patients in the STgroup had a bad prognosis. Six (40 %) needed a diet; 4 (50 %) laxatives or enemas and 1 (10 %) a cecostomy button for antegrade enemas. CONCLUSIONS Patients with RvaF had a high index of associated anomalies. The difference of operative time was not statistically significative. No differences in functional results between both groups were observed. LT is a valid option to treat RvaF.
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Affiliation(s)
- Maria Marcela Bailez
- Division of Pediatric Surgery, Garrahan Children 's Hospital, Buenos Aires, Argentina.
| | - Paula Lorena Roumieu
- Division of Pediatric Surgery, Garrahan Children 's Hospital, Buenos Aires, Argentina
| | - Lucila Alvarez
- Division of Pediatric Surgery, Garrahan Children 's Hospital, Buenos Aires, Argentina
| | - Vanesa Martinez
- Division of Pediatric Surgery, Garrahan Children 's Hospital, Buenos Aires, Argentina
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Chatterjee US, Basu AK, Das S, Mitra D. Abdominoperineal Tunnel Crafted with Alken's Telescopic Dilators: A Novel Technique! J Indian Assoc Pediatr Surg 2021; 26:334-335. [PMID: 34728920 PMCID: PMC8515534 DOI: 10.4103/jiaps.jiaps_129_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/23/2020] [Accepted: 08/04/2020] [Indexed: 11/04/2022] Open
Abstract
Background Abdomino-perineal pull through procedure needs perineal dissection and for that swap of supine to prone may be necessary. To avoid that as well as to avoid neuro-muscular damage; we are describing a simple minimal invasive procedure with help of Alken's telescopic dilators. Patients & Methods We created abdomino-perineal tunnel with Alken's telescopic dilators to bring down the lumen of intestine in perineum in eight patients. Results Operative time happened to be less and procedure found to be less traumatic. All the eight patients had satisfactory outcome. Conclusions Actually, we have repurposed the Alken's dilator for creation of abdomino-perineal tunnel or track to get benefit of minimal dissection of perineum during pull-through procedure as well as to avoid neuro-muscular damage.
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Affiliation(s)
| | - Ashoke Kumar Basu
- Department of Pediatric Surgery, Park Clinic, Kolkata, West Bengal, India
| | - Sachchidananda Das
- Department of Pediatric Surgery, Park Clinic, Kolkata, West Bengal, India
| | - Debashis Mitra
- Department of Pediatric Surgery, Park Clinic, Kolkata, West Bengal, India
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Li L, Ming A, Zhou Y, Xu H, Sun H, Li Q, Li X, Zhang Z, Diao M, Xie X. Refinements in surgical techniques for visualized tunnel formation in laparoscopic-assisted anorectoplasty. Pediatr Surg Int 2021; 37:999-1005. [PMID: 33903971 DOI: 10.1007/s00383-021-04909-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Laparoscopic-assisted anorectoplasty (LAARP) is becoming a more popular procedure for anorectal malformation (ARM) repair. However, the conventional technique for creating pull-through tunnel between the perineal skin and the pelvic floor has been criticized as being semi-blind. This study aims to present a refined version of our previously reported clamp introduction technique for visualized tunnel formation in the center of the sphincter muscle complex (SMC) for rectal pull- through for ARMs. METHODS A retrospective review was performed for ARM patients who underwent LAARP from Jan 2019 to Jun 2020. Longitudinal muscle tube (LMT) tunnel was created using the clamp-dilator introduction technique: a laparoscopic dilator was used to create a pelvic tunnel within LMT in high ARM, and the clamp introduction under the direct vision technique was performed for creating the perineal tunnel of LMT for both high and intermediate ARMs. RESULTS Seventy patients (1-198 days) with high-type (27cases) and intermediate-type (43 cases) ARM underwent LAARP using clamp-dilation introduction technique. No patients suffered from urinary tract injury, recurrent rectourethral fistula, urethral diverticulum and urinary incontinence. One patient suffered from wound infection and rectal retraction which required a redo pull-through on postoperative day 7. Rectal prolapse requiring surgical intervention developed in one patient. Postoperative MRI examination confirmed central placement of the rectum within the LMT in all cases. CONCLUSION Our experience demonstrates that a visualized tunnel formation in the LMT center can be achieved by the clamp-dilator introduction technique in LAARP for both high and intermediate ARMs.
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Affiliation(s)
- Long Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China.
| | - Anxiao Ming
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Yan Zhou
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China.,Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Hang Xu
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Hailin Sun
- Department of Medical Imaging, Capital Institute of Pediatrics, Beijing, 100020, People's Republic of China
| | - Qi Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Xu Li
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Zhen Zhang
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China
| | - Mei Diao
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China.
| | - Xianghui Xie
- Department of Pediatric Surgery, Capital Institute of Pediatrics, No.2 Yabao Road, Chaoyang District, Beijing, 100020, People's Republic of China.
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Ishimaru T, Kawashima H, Hayashi K, Omata K, Sanmoto Y, Inoue M. Laparoscopically assisted anorectoplasty-Surgical procedures and outcomes: A literature review. Asian J Endosc Surg 2021; 14:335-345. [PMID: 33029900 DOI: 10.1111/ases.12877] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/08/2020] [Accepted: 09/22/2020] [Indexed: 11/27/2022]
Abstract
Anorectal malformation includes various types of anomalies. The goal of definitive surgery is achievement of fecal continence. Twenty years have passed since laparoscopically assisted anorectoplasty (LAARP) was reported by Georgeson. Since LAARP is gaining popularity, its long-term outcomes should be evaluated. Presently, there is no evidence regarding the optimal method of ligating and dividing the fistula correctly and creating the pull-through canal accurately. Rectal prolapse and remnant of the original fistula (ROOF) tend to develop more often in LAARP patients than in posterior sagittal anorectoplasty (PSARP) patients; however, robust evidence is not available. Prolapse may be prevented by suture fixation of the rectum to the presacral fascia; however, if prolapse occurs, the indication, timing, and the best method for surgical correction remain unclear. Most patients with ROOF are asymptomatic, and there is controversy regarding the indications for ROOF resection. This article aimed to detail the various modifications of the LAARP procedures reported previously and to describe the surgical outcomes, particularly focusing on rectal prolapse, ROOF, and fecal continence, by reviewing the literature. Functional outcomes after LAARP were almost similar to those noted after PSARP, and we have demonstrated that LAARP is not inferior to PSARP with respect to fecal continence. Although there is controversy regarding the application of LAARP for recto-bulbar cases, we believe that LAARP is still evolving, and we can achieve better outcomes by improving the procedure.
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Affiliation(s)
- Tetsuya Ishimaru
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroshi Kawashima
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Kentaro Hayashi
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Kanako Omata
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Yohei Sanmoto
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Maho Inoue
- Division of Pediatric Surgery, Saitama Children's Medical Center, Saitama, Japan
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Bandi AS, Bradshaw CJ, Giuliani S. Advances in minimally invasive neonatal colorectal surgery. World J Gastrointest Surg 2016; 8:670-678. [PMID: 27830038 PMCID: PMC5081548 DOI: 10.4240/wjgs.v8.i10.670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 07/27/2016] [Accepted: 08/18/2016] [Indexed: 02/06/2023] Open
Abstract
Over the last two decades, advances in laparoscopic surgery and minimally invasive techniques have transformed the operative management of neonatal colorectal surgery for conditions such as anorectal malformations (ARMs) and Hirschsprung’s disease. Evolution of surgical care has mainly occurred due to the use of laparoscopy, as opposed to a laparotomy, for intra-abdominal procedures and the development of trans-anal techniques. This review describes these advances and outlines the main minimally invasive techniques currently used for management of ARMs and Hirschsprung’s disease. There does still remain significant variation in the procedures used and this review aims to report the current literature comparing techniques with an emphasis on the short- and long-term clinical outcomes.
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Abstract
Seventeen years have passed since the first description of the laparoscopic approach for anorectal malformation and approximately 68 articles have been published on the subject. In this review article, we aim to describe the advantages as well as the indications and contraindications of this approach when dealing with each specific type of anorectal malformation, according to what has been described in the literature and to our own experience. The ideal and undisputable indication for laparoscopy remains for cases in which the abdomen needs to be entered to repair the malformation. Only 10% of male patients with anorectal malformation are born with a recto-bladder neck fistula that requires an abdominal approach, this represents an ideal indication for laparoscopy. In females, only the complex cloacae with a common channel length greater than 3 cm are the ones that require a laparotomy; they represent about 30% of the cloacae. However, the repair of this type of cloacae also requires sophisticated and technically demanding maneuvers that have never been done laparoscopically. In cases of recto-urethral prostatic fistulas the malformation can be repaired either way: laparoscopically or posterior sagitally. In all other malformations: recto-perineal fistula, recto-urethral bulbar fistula, anorectal malformation without fistula, rectal atresia, recto-vestibular fistula; no justification for laparoscopy could be found; and in some cases, laparoscopy is contraindicated. In the published reports, there is no evidence supporting the idea that laparoscopic repair results in better functional results when compared with non-laparoscopic operation; there is a tendency to omit information relevant to bowel control such as the characteristics of the sacrum and the presence or absence of tethered cord; and most authors do not compare results between comparable malformations.
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Koga H, Ochi T, Okawada M, Doi T, Lane GJ, Yamataka A. Comparison of outcomes between laparoscopy-assisted and posterior sagittal anorectoplasties for male imperforate anus with recto-bulbar fistula. J Pediatr Surg 2014; 49:1815-7. [PMID: 25487490 DOI: 10.1016/j.jpedsurg.2014.09.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 09/05/2014] [Indexed: 11/19/2022]
Abstract
PURPOSE All reports comparing laparoscopy-assisted anorectoplasty (LAARP) with posterior sagittal anorectoplasty (PSARP) in male high-type imperforate anus include a mix of recto-vesical, recto-prostatic, recto-bulbar, and absent fistula cases without focusing on recto-bulbar fistula (RBF), the most challenging type to treat laparoscopically. We compared LAARP with PSARP for treating only RBF. METHOD We used our fecal continence evaluation questionnaire (FCE; maximum score=10), scoring of magnetic resonance imaging (MRI) findings (MRI scores), and the angle between the rectum and the anal canal (RAA) to assess 20 RBF cases (LAARP=12, PSARP=8) treated from 2000 to 2013 prospectively. RESULTS Mean ages at surgery, MRI scores, mean RAA, and duration of raised C-reactive protein (6.6 vs. 6.7days; p=NS) were similar. In all cases, postoperative MRI showed no residual fistula and normal urination. LAARP had consistently higher FCE (7.9 vs. 7.8 at 3years; 8.6 vs. 8.3 at 5years; 8.9 vs 8.6 at 7years; p=NS, respectively), less wound infections (0 vs. 37.5%; p<0.05), higher incidence of rectal mucosal prolapse (50.0 vs. 0%; p<0.05), and required less analgesia (p<0.05). CONCLUSION Although LAARP and PSARP are comparable for treating RBF, LAARP is associated with less wound infections and higher incidence of rectal mucosal prolapse.
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Affiliation(s)
- Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo Japan.
| | - Takanori Ochi
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo Japan
| | - Manabu Okawada
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo Japan
| | - Takashi Doi
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo Japan
| | - Geoffrey J Lane
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo Japan
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo Japan
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Abstract
Laparoscopically assisted anorectal pull-through (LAARP), first described by Georgeson, is now considered to be the radical surgical treatment of choice for rectourethral fistula (RUF) in boys with high/intermediate-type imperforate anus. Accurate positioning of the pull-through canal, with pelvic floor muscles surrounding it symmetrically, is well recognized as the most important prognostic factor irrespective of the procedure performed. Surgical intervention should be LAARP with intraoperative measurement of the RUF, with follow-up focused on bowel habit. Complications such as diverticulum formation, have been reported with increasing frequency after LAARP and are most likely related to incomplete excision of the RUF, especially in bulbar cases. Thus, complete excision, while technically challenging, is crucial. Based on the results of a multicenter study comparing LAARP with other surgery, the most reliable investigation for detecting the presence of a diverticulum is MRI. At Juntendo University Hospital in Tokyo, Japan, blunt dissection with mosquito forceps to identify the potential pull-through canal, measuring the length of the RUF directly, and closer placement of trocars (in bulbar fistula cases) are homegrown refinements that we feel improve outcome and we present a review of our approach to the surgical management of ARM.
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Affiliation(s)
- Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan,
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Yamataka A, Goto S, Kato Y, Koga H, Lane GJ, Okazaki T. Fecal and urinary continence after scope-assisted anorectovaginoplasty for female anorectal malformation. Pediatr Surg Int 2012; 28:907-12. [PMID: 22940880 DOI: 10.1007/s00383-012-3141-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM We assessed continence after scope-assisted anorectovaginoplasty (SARVP) for female anorectal malformation (FARM). METHODS Five FARM cases were assessed; cases 1 and 2: cloacal malformation; case 3: urogenital sinus, and rectovestibular fistula (RF); case 4: RF, absent vagina, and sacral anomaly; case 5: covered cloacal exstrophy. Treatment was SARVP in all cases, with perineal vaginoplasty (case 1), vagina pull-through (PT) similar to Georgeson's colon PT (case 2), and the use of the native RF/cloaca channel as a vagina (cases 3-5). Continence was assessed pre and postoperatively. RESULTS SARVP was performed in the lithotomy position without repositioning. Mean age at surgery was 3.2 (1.7-5.5) years. Current mean age: 8.8 years (range 7.5-12.2). Mean follow-up: 5.7 years. Preoperative continence: fecal: all had stomas; urinary: cases 1 and 2: continent; cases 3-5: incontinent. Postoperative continence: fecal: cases 1-3: continent; case 4: incontinent; case 5: awaiting stoma closure; urinary: cases 1 and 2: continent; cases 3 and 4: incontinent; case 5: continent (intermittent catheterization). Fetal continence evaluation questionnaire (CEQ) scores for cases 1-4 were 7.5, 9, 10, and 2 (maximum score 10, mean 7.1). CONCLUSION Scope assistance improves visualization, thus pelvic sphincter dissection/division is minimized with less detrimental impact on postoperative continence.
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Affiliation(s)
- Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
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Miglani RK, Murthy D, Bhat RS, Ashok KKV. Anorectal anomalies in adults-laparoscopic management and review of literature. Indian J Surg 2012; 74:301-4. [PMID: 23904718 DOI: 10.1007/s12262-011-0394-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 12/21/2011] [Indexed: 10/14/2022] Open
Abstract
Anorectal malformations (ARMs) are one of the most common congenital anomalies dealt by surgeons. The reported incidence of ARMs range between 1:3,300 and 1:5,000 live births. These defects are invariably detected and treated in infancy or early childhood. There is a group of patients among these who have fistulous external opening from the rectum. These may not present in child hood and may continue to live with fecal incontinence till adult hood. One of such anomalies is rectovaginal fistulas which comprises of only 4% of all anomalies. Delayed management in such cases increases surgical and functional complications. Traditionally high and intermediate anorectal anomalies are treated by posterior sagittal anorectoplasty (PSARP). This involves cutting of sphincter muscles in the midline and then placement of rectum in the sphincter complex. The continence results of this operation are less than ideal. Laparoscopically assisted anorectal pull-through (LAARP) has potential advantage of precise placement of the rectum inside the sphincter complex without dividing and weakening the muscles, diminished soft tissue scarring around the rectum leading to improved rectal compliance. Three adult female patients with ARMs were managed through LAARP procedure. It involves dissection around rectum, identification and ligation of fistula tract, creation of neoanus and pull through of rectum into neoanus. Results-Continence was good in all our patients which they regained after 3 to 4 days of surgery. On follow up which ranged from 6 months to 2 years all were passing well formed stools 1-2 times a day and have symmetric anal contraction with strong squeeze on digital rectal examination. Conclusion-LAARP offers an excellent option to the patients of ARM over conventional posterior sagittal anorectal approach because if its theoretical advantages of early recovery and better continence. Long term followup is needed to substantiate these results.
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Affiliation(s)
- Ripan K Miglani
- Department of Surgical Gastroenterology, Bangalore Medical College and Research Institute, Bangalore, India ; 67 B Tagore Nagar, Civil Lines, Ludhiana, Punjab 141001 India
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Tong QS, Tang ST, Pu JR, Mao YZ, Wang Y, Li SW, Cao QQ, Ruan QL. Laparoscopically assisted anorectal pull-through for high imperforate anus in infants: intermediate results. J Pediatr Surg 2011; 46:1578-86. [PMID: 21843727 DOI: 10.1016/j.jpedsurg.2011.04.059] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Revised: 03/19/2011] [Accepted: 04/27/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to evaluate the clinical outcomes and postoperative anal function in infants with congenital high imperforate anus treated with laparoscopically assisted anorectal pull-through (LAARP). METHODS From January 2004 to July 2007, 33 patients (28 boys and 5 girls, age ranging from 3 to 10 months) with high imperforate anus underwent LAARP. Clinical data of the LAARP group were retrospectively compared with those treated by posterior sagittal anorectoplasty (PSARP; n = 28) during the same time period. Anorectal function of these patients was evaluated using the following 3 methods: the Kelly score, anorectal vector volume manometry, and magnetic resonance imaging between the ages of 3.1 and 4.4 years. RESULTS The mean operative time in LAARP and PSARP groups was 112.5 ± 12.4 and 120.4 ± 18.5 minutes (P > .05), respectively. The mean length of hospital stay in the LAARP group was shorter than that of PSARP group (11.3 ± 2.1 vs 14.6 ± 2.3 days, P < .01). No significant difference was observed between LAARP and PSARP groups regarding the Kelly score (3.52 ± 1.42 vs 3.49 ± 0.82). Although magnetic resonance imaging revealed lower malposition rates of rectum in the LAARP group than those of the PSARP group at both I-line (3.0% vs 14.3%) and M-line (3.0% vs 10.7%) levels, this was not statistically different (P > .05). Compared with the PSARP group, lower asymmetric index, larger vector volume, and higher anal canal pressure at rest and during voluntary squeeze were observed in LAARP group (P < .05). However, there were no significant differences in the length of high-pressure zone (15.2 ± 5.8 vs 15.1 ± 6.2 mm) and the presence of rectoanal relaxation reflex (84.8% vs 85.7%). CONCLUSIONS Satisfactory fecal continence can be achieved in patients with high-type imperforate anus after LAARP. Laparoscopically assisted anorectal pull-through has advantages over PSARP, including shorter hospital stay and better position of rectum. However, long-term follow-up is necessary to compare the benefits of LAARP against PSARP.
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Affiliation(s)
- Qiang-song Tong
- Department of Pediatric Surgery, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, PR China
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Bischoff A, Levitt MA, Peña A. Laparoscopy and its use in the repair of anorectal malformations. J Pediatr Surg 2011; 46:1609-17. [PMID: 21843731 DOI: 10.1016/j.jpedsurg.2011.03.068] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Revised: 03/25/2011] [Accepted: 03/25/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Laparoscopy has been used for the treatment of anorectal malformations (ARMs) in an attempt to be less invasive and with the hope that it would result in a better functional outcome. There remains a significant debate about whether these expectations have been fulfilled. METHODS Seventeen patients with ARM for whom laparoscopy was used were retrospectively reviewed. Six were operated on primarily by the authors, and 11 cases were referred after a laparoscopic repair performed elsewhere. In addition, a literature review was performed looking for evidence of less invasiveness and improved functional results in patients operated on laparoscopically. RESULTS The diagnosis was imperforate anus with a rectobladder neck fistula in our 6 cases with the fistula ligated laparoscopically in each case. In 1 patient, the malformation was repaired entirely using laparoscopic technique. The other 5 patients had a laparoscopically assisted repair because we had to open the abdomen to taper a dilated rectum in 2, mobilize a very high rectum in 2, and take down a distal colostomy stoma in 1. Eleven patients were referred with a variety of problems after a laparoscopic repair done elsewhere for rectal stricture (5), rectal prolapse (4), recurrent rectourethral fistula (3), rectal mislocation (3), failed attempted repair leading to fecal incontinence (1), and a posterior urethral diverticulum (1). Our literature review included 47 references (involving 323 patients) published between 1998 and 2010. All studies showed that laparoscopic repair of ARMs is feasible. The review, however, did not provide evidence of less invasiveness or improved functional results. CONCLUSIONS Laparoscopy for ARM is a less invasive procedure when compared with those operations that would have previously required a laparotomy (rectobladder neck fistula). In cases of rectoprostatic fistulae, the laparoscopic approach is feasible and avoids a lengthy posterior sagittal incision. There is no evidence that the laparoscopic approach is a less invasive procedure for other types of ARMs. In cases of rectobulbar fistula, congenital anal stenosis, perineal fistula, ARM without fistula, the evidence suggests that it may be lead to more complications. There is no evidence in the literature demonstrating better functional results in cases of ARM operated on laparoscopically.
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Bailez MM, Cuenca ES, Mauri V, Solana J, Di Benedetto V. Outcome of males with high anorectal malformations treated with laparoscopic-assisted anorectal pull-through: preliminary results of a comparative study with the open approach in a single institution. J Pediatr Surg 2011; 46:473-7. [PMID: 21376195 DOI: 10.1016/j.jpedsurg.2010.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 07/08/2010] [Accepted: 08/06/2010] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The aim of this study was to analyze the outcome of males with HARM treated with a laparoscopic-assisted anorectal pull-through compared with the open posterior sagittal approach in a single institution. METHODS This study includes 32 patients: 17 (9 with a rectoprostatic fistula [RPF] and 8 with a rectovesical fistula [RVF]) who underwent laparoscopic-assisted anorectal pull-through from October 2001 onward and 15 (8 with an RPF and 7 with an RVF) treated by posterior sagittal approach before that date. Patients were reviewed retrospectively but were operated on by the authors and had longitudinal follow-up. Parameters analyzed included associated anomalies, sacral ratio (SR) index, age at surgery, operative time, complications, presence of voluntary bowel movements, constipation, and soiling. A good outcome was determined by absent or grade 1 soiling and a poor outcome result by soiling grades 2 and 3. RESULTS Mean age at surgery was 22 and 37.5 months for patients with RPF and RVF, respectively, in the laparoscopic group and 29.2 and 25.7 months in the open group. Operative time was significantly shorter (P < .0036) for the laparoscopic RVF repair compared with the open approach. In patients with RPF, 50% in the laparoscopic (L) and 37.5% in the open (O) approach had an SR below 0.6. Fifty percent of all patients with RVF had an SR below 0.6, making groups comparable in terms of evaluating bowel function. Four patients were excluded in the analysis of functional results. Voluntary bowel movements with previous defecatory sensation were present in 83.l3% (5/6) in L vs 87.5% (7/8) in O patients with RPF and 62.5% (5/8) L vs 50% (3/6) in O patients with RVF. Grade 1 soiling was present in 50% (3/6) vs 62.5% (5/8) of patients with RPF and 37.5% (3/8) vs 16% (1/6) of patients with RVF in the L and O groups, respectively. Soiling grade 2 or 3 was present in 50% (3/6) vs 12.5% (1/8) of patients with RPF and 37.5% (3/8) vs 50% (3/6) of patients with RVF in the L and O groups, respectively. The risk of poor outcome was 61% in the group with SR lower than 0.6 vs 13% in the group with a higher ratio. By stratifying the groups according to type of surgery or anatomical type, these results were maintained. CONCLUSION The laparoscopic approach is a reasonable surgical option for the management of HARM. Laparoscopic approach was less time consuming in patients with RVF without impairing functional results.
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Affiliation(s)
- Maria M Bailez
- Division of Pediatric Surgery, Garrahan Children's Hospital, Buenos Aires, Argentina.
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Al-Hozaim O, Al-Maary J, AlQahtani A, Zamakhshary M. Laparoscopic-assisted anorectal pull-through for anorectal malformations: a systematic review and the need for standardization of outcome reporting. J Pediatr Surg 2010; 45:1500-4. [PMID: 20638532 DOI: 10.1016/j.jpedsurg.2009.12.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2009] [Revised: 10/30/2009] [Accepted: 12/04/2009] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Laparoscopic-assisted anorectal pull-through (LAARP) is becoming an increasingly common procedure to correct high and intermediate anorectal malformations (ARMs). The aim of this review was to evaluate worldwide experiences with LAARP with regard to indications, outcomes, and quality of reporting. METHOD A systematic review was conducted. The search was limited to studies reported in English and performed in humans. In addition to Medline and PubMed, a manual search of the Journal of Pediatric Surgery, Pediatric Surgery International, Surgical Endoscopy, and the Journal of Laparoendoscopic & Advanced Surgical Techniques published between June 2000 and April 2008 was conducted. RESULTS Seventeen studies were included in the final analysis. Of the included studies, none were randomized, 2 were prospective in nature, and 4 compared outcomes of posterior sagittal anorectoplasty and LAARP. The studies included 124 patients (96 males, 28 females) with 80% reported as having high/intermediate malformations. All studies reported short-term outcomes. Reported outcomes included continence, rectal prolapse, the position of the rectum (7 studies using Kelly score), manometry (1 study), contrast enema (1 study), postanal endosonography (3 studies), and postoperative magnetic resonance imaging (3 studies). Outcomes varied widely between reports precluding a meta-analysis. CONCLUSION The number of studies dealing with LAARP is low. There is a need for both a standardization and improvement in the quality of reporting in LAARP research. This will ultimately allow for evidence-based surgical decision making.
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Affiliation(s)
- Omar Al-Hozaim
- Division of Pediatric Surgery, King Saud bin Abdulaziz University for Health Sciences University, Riyadh 1446, Saudi Arabia
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15
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Hay SA. Transperineal rectovesical fistula ligation in laparoscopic-assisted abdominoperineal pull-through for high anorectal malformations. J Laparoendosc Adv Surg Tech A 2009; 19 Suppl 1:S77-9. [PMID: 19260798 DOI: 10.1089/lap.2008.0157.supp] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Rectovesical fistula ligation after laparoscopic mobilization of the rectum requires either cutting of the fistula and application of endo-loop or laparoscopic endoligation or clip application. These techniques take more time and require a well-trained surgeon for performing the ligation laparoscopically. A simple technique for ligation of the fistula will be described. MATERIALS AND METHODS Over the last 5 years, laparoscopic-assisted abdominoperineal pull-through was performed in 12 cases with high anorectal malformation with rectovesical or rectoprostatic fistula. The rectovesical fistula was mobilized initially laparoscopically. The anal site was identified using muscle stimulator and incised at its center. A Hegar dilator was passed through the center of the anal sphincter to exit behind the fistula seen by laparoscopy. The tract was dilated with Hegar dilators till reaching a suitable size for rectal pull-through. A straight clamp holding the ligature was passed through the perineal site and through the dilated tract to emerge on one side of the fistula; then, the ligature was grasped through the abdomen and turned around the junction of the fistula, forming a loop and regrasped and brought outside with the clamp. The two ends of the ligature emerging from the perineal site were tied, and the knot was pushed using the finger till it reached the fistula, and then it was ligated. The fistula was cut and the mobilized rectum was pulled through the perineal incision to be sutured at the site of the future anus. RESULTS Twelve patients with imperforate anus with rectovesical or rectoprostatic fistula had fistula ligation with this technique. Their ages ranged from 3 to 9 months. Ligation of the fistula was possible in all patients. Operative time ranged from 90 to 120 minutes (mean 110 minutes). The ascending urethrogram showed no residual diverticulum in all but one case, which presented with difficulty in micturation and needed to be excised. CONCLUSION Transperineal rectovesical fistula ligation in laparoscopic-assisted abdominoperineal pull-through for high anorectal malformations is an alternative technique for fistula ligation during laparoscopy. It is simple and easy to perform with acceptable postoperative results.
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Yamataka A, Kato Y, Lee KD, Lane G, Kusafuka J, Okazaki T. Endoscopy-assisted laparoscopic excision of rectourethral fistula in a male with imperforate anus. J Laparoendosc Adv Surg Tech A 2009; 19 Suppl 1:S241-3. [PMID: 18999979 DOI: 10.1089/lap.2008.0144.supp] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We report a surgical technique that we developed to facilitate complete excision of rectourethral fistula (RUF)in male patients with imperforate anus (IA). A 6-month-old boy with rectobulbar urethral fistula (bulbar-RUF)had laparoscopic repair of IA. During laparoscopic dissection of the RUF, a fine flexible endoscope was inserted into the rectum through an opening made in the anterior rectal wall. Endoscopy of the rectum allowed the level of laparoscopic dissection to be observed intraluminally, allowing the bulbar-RUF to be excised exactly at its distal end. He is well after follow-up of 9 months with no evidence of residual RUF on radiologic investigations.We have since used this technique to treat another IA patient with prostatic-RUF successfully.
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Affiliation(s)
- Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan.
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Podevin G, Petit T, Mure PY, Gelas T, Demarche M, Allal H, Becmeur F, Varlet F, Philippe P, Weil D, Heloury Y. Minimally Invasive Surgery for Anorectal Malformation in Boys: A Multicenter Study. J Laparoendosc Adv Surg Tech A 2009; 19 Suppl 1:S233-5. [DOI: 10.1089/lap.2008.0137.supp] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | | | | | | | - François Becmeur
- Department of Paediatric Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - Paul Philippe
- Pediatric Surgery Luxembourg, Luxembourg, Luxembourg
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Iwanaka T. Technical innovation, standardization, and skill qualification for pediatric minimally invasive surgery in Japan. J Pediatr Surg 2009; 44:36-42. [PMID: 19159715 DOI: 10.1016/j.jpedsurg.2008.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2008] [Accepted: 10/07/2008] [Indexed: 11/27/2022]
Abstract
This is a presentation of sharing endeavors at modifying and standardizing surgical procedures as well as establishing endoscopic surgical skill qualification in the field of pediatric surgery in Japan.
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Affiliation(s)
- Tadashi Iwanaka
- Department of Pediatric Surgery, University of Tokyo Graduate School of Medicine, Tokyo, Japan.
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Yamataka A, Kato Y, Lee KD, Lane G, Kusafuka J, Okazaki T. Endoscopy-Assisted Laparoscopic Excision of Rectourethral Fistula in a Male with Imperforate Anus. J Laparoendosc Adv Surg Tech A 2008. [DOI: 10.1089/lap.2008.0144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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20
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Podevin G, Petit T, Mure PY, Gelas T, Demarche M, Allal H, Becmeur F, Varlet F, Philippe P, Weil D, Heloury Y. Minimally Invasive Surgery for Anorectal Malformation in Boys: A Multicenter Study. J Laparoendosc Adv Surg Tech A 2008. [DOI: 10.1089/lap.2008.0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Srimurthy KR, Ramesh S, Shankar G, Narenda BM. Technical modifications of laparoscopically assisted anorectal pull-through for anorectal malformations. J Laparoendosc Adv Surg Tech A 2008; 18:340-3. [PMID: 18373473 DOI: 10.1089/lap.2006.0247] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Our technique of fistula ligation and centering of bowel during the laparoscopically-assisted anorectal pull-through (LAARP) for the high-imperforate anus is described. METHODS The distal rectum is dissected laparoscopically. About 1 in proximal to the termination of the rectum, we commence a subseromuscular dissection to create a mucosal tube of the distal rectum up to the urethra. This mucosal tube is then ligated and sharply divided. Under laparoscopic guidance, the needle is inserted between the two bellies of Levator Ani muscle, just posterior to the urethra. Simultaneous external stimulation confirms the optimal position. A guide wire is then passed through the needle. The tract is serially dilated and the anoplasty completed. RESULTS This technique has overcome the problem of residual urethral diverticulum in our cases.
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Affiliation(s)
- Kadaba R Srimurthy
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bangalore, India
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Ponsky TA, Rothenberg SS. Minimally invasive surgery in infants less than 5 kg: experience of 649 cases. Surg Endosc 2008; 22:2214-9. [PMID: 18649102 DOI: 10.1007/s00464-008-0025-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Revised: 05/08/2008] [Accepted: 05/20/2008] [Indexed: 10/21/2022]
Abstract
INTRODUCTION With the development of advanced skills and the introduction of miniature laparoscopic tools, endoscopic procedures in infants and small children have become possible. This report documents our experience in minimally invasive surgery (MIS) in infants under 5 kg. METHODS A retrospective database review was performed from September 1993 to September 2007. All children weighing 5 kg or less that underwent a laparoscopic or thoracoscopic procedure were included. RESULTS A total of 649 cases were attempted. 43 different procedures were performed, the most common being Nissen fundoplication (310 cases, average operating room (OR) time 43 min, average time to full feeds 2 days), pyloromyotomy (104 cases, average OR time 12.5 min, average hospital days<1), patent ductus arteriosum (PDA) ligation (26 cases, average OR time 31 min, average hospital days<1), tracheoesophageal fistula (TEF) repair (22 cases, average OR time 83 min, average time to full feeds 7.8 days), duodenoduodenostomy (20 cases, average OR time 76 min, average time to full feeds 8.6 days), colonic pull-through for Hirschsprung's disease (18 cases, average OR time 109.6 min, average time to full feeds 3 days), colonic pull-through for imperforate anus (10 cases, average OR time 103 min, average hospital days 2), lung resection (12 cases, average OR time 66.8 min, average hospital days 1.75), congenital diaphragmatic hernia repair (10 cases, average OR time 62.5 min, average time to full feeds 4.75 days). There were no surgery-related deaths. The conversion rate to open was 1.2% (n=8). There were six intraoperative complication rate (0.9%) and the overall complication rate was 3% (20 complications overall). CONCLUSIONS The development of modern low-flow CO2 insufflators, smaller instruments and telescopes, as well as advanced techniques, has made MIS in neonates feasible and safe. The greatest challenge remains performing intestinal anastomosis in these confined spaces, and further technical advances will be required to make these techniques universally adopted.
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Affiliation(s)
- Todd A Ponsky
- Rocky Mountain Hospital for Children, Denver, CO, USA
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Abstract
Complete covered cloacal exstrophy (CCCE) is extremely rare. The anatomy of CCCE is complex and often unique, and each case must be treated individually. We present the case of a 5-year-old girl with CCCE whom we treated successfully with great improvement in her quality of life.
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Affiliation(s)
- Masaaki Oshita
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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Lima M, Tursini S, Ruggeri G, Aquino A, Gargano T, De Biagi L, Ahmed A, Gentili A. Laparoscopically assisted anorectal pull-through for high imperforate anus: three years' experience. J Laparoendosc Adv Surg Tech A 2006; 16:63-6. [PMID: 16494552 DOI: 10.1089/lap.2006.16.63] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
PURPOSE We describe our three-year experience with the laparoscopically assisted anorectal pullthrough for high imperforate anus using laparoscopic muscle electrostimulation. MATERIALS AND METHODS From March 2001 to January 2004, 7 patients with a diagnosis of high anorectal malformation underwent laparoscopically assisted anorectal pull-through. The patients, all males aged from 4 to 9 months (mean age, 5.8 months), presented with a rectourethral fistula. The associated malformations noted were sacral malformation, laryngeal stenosis, urethral duplication, multicystic kidney, nonpalpable testis, and esophageal atresia. All patients were treated with a colostomy in the newborn period followed by a delayed laparoscopically assisted anorectal pullthrough. Laparoscopy included stimulation of the puborectal muscle, using a modified Peña electrostimulator introduced through a trocar. All patients underwent a postoperative period of anal dilatation. RESULTS In 6 cases the laparoscopically assisted anorectal pull-through was successful; there was 1 conversion to the open technique, due to strong tension from the colostomy. CONCLUSION Although longer follow-up to evaluate continence is to come, laparoscopically assisted anorectal pull-through should be considered for the correction of the high imperforate anus and, according to our experience, it represents the gold standard. It offers the advantage of good visualization of the fistula and the surrounding structures and minimally invasive abdominal and perineal wounds. With the laparoscopic Peña stimulator the direct observation of the contraction of the puborectalis sling allows an evaluation of the functional contractility and an accurate colonic pullthrough in the center of the muscle complex.
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Affiliation(s)
- Mario Lima
- Department of Pediatric Surgery, University of Bologna Policlinico S. Orsola-Malpighi, via Massarenti 11, 40138 Bologna, Italy.
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Kubota A, Kawahara H, Okuyama H, Oue T, Tazuke Y, Tanaka N, Okada A. Laparoscopically assisted anorectoplasty using perineal ultrasonographic guide: a preliminary report. J Pediatr Surg 2005; 40:1535-8. [PMID: 16226979 DOI: 10.1016/j.jpedsurg.2005.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND/PURPOSE As minimal invasive surgery, laparoscopically assisted anorectal pull-through has been reported with new devices. However, it is not easy to create an accurate pull-through canal (PTC) because of the narrow space between the urethra and puborectal sling. The authors describe a new method using perineal ultrasonography. METHODS The rectourethral prostatic fistula was dissected laparoscopically. Externally, electrostimulation identified the center of the muscle contraction, over which a 1.2-cm skin incision was made, and the lower part of PTC was created by hemostat forceps guided by electrostimulation. An ultrasonographic probe applied to the perineum demonstrated the urethra, and the forceps was advanced behind the urethra into the pelvic cavity using the ultrasonographic guide. Anorectal pull-through was performed after dilatation of the PTC with dilators. RESULTS The authors applied this procedure in 5 cases of male high and intermediate anomalies. Surgical damages to the urethra and the levator and vertical muscles were not encountered. Postoperative fluoroscopic study demonstrated good anterior angulation and intact contraction and relaxation of those muscles. CONCLUSION The combination of laparoscopic dissection, pinpointing the center of anal sphincter by electrostimulation, and identification of the urethra by ultrasonographic images from the perineum facilitated creation of appropriate PTC in the muscle complex.
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Affiliation(s)
- Akio Kubota
- Department of Pediatric Surgery, Osaka Medical Center, Research Institute for Maternal and Child Health, Osaka 594-1101, Japan.
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Koga H, Okazaki T, Yamataka A, Kobayashi H, Yanai T, Lane GJ, Miyano T. Posterior urethral diverticulum after laparoscopic-assisted repair of high-type anorectal malformation in a male patient: surgical treatment and prevention. Pediatr Surg Int 2005; 21:58-60. [PMID: 15338176 DOI: 10.1007/s00383-004-1265-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Currently, laparoscopic-assisted colon pull-through (LACPT) is the treatment of choice for male patients with high-type imperforate anus and rectourethral fistula. Since laparoscopy was introduced for treating this condition, reports concerning post-LACPT complications are rare. Here we discuss the case of a boy, now 3.5 years old, born at 37 weeks' gestation weighing 2,300 g, who was diagnosed with rectobulbar urethral fistula (RUF) at birth. LACPT was performed when the boy was 11 months old and weighed 7.2 kg. No intraoperative complications occurred, and the initial post-LACPT course was uneventful. When he was 2 years old, he developed dysuria requiring urethral catheterization. Diagnostic radiology confirmed a large cystic mass behind the bladder, suggestive of a posterior urethral diverticulum (PUD). Histopathology of the excised mucosa of the cyst showed colonic mucosa, confirming that the cyst was indeed an enlarged residual RUF. We discuss our treatment and our approach to prevention.
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Affiliation(s)
- Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, 113-8421 Bunkyo-ku, Tokyo, Japan
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Abstract
Minimally invasive surgery has been one of the most important surgical advances in the last 15 years. The development of smaller instruments has allowed pediatric surgeons to apply this rapidly evolving technology to neonates. Congenital neonatal deformities including tracheoesophageal fistula, patent ductus arteriosus, duodenal atresia and anorectal malformations are now being managed with minimally invasive surgery. This article summarizes the status of these techniques in neonates.
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Affiliation(s)
- Keith E Georgeson
- Division of Pediatric Surgery, Children's Hospital of Alabama, University of Alabama, Birmingham, AL, USA
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Tei E, Yamataka A, Segawa O, Kobayashi H, Lane GJ, Tobayama S, Kameoka S, Miyano T. Laparoscopically assisted anorectovaginoplasty for selected types of female anorectal malformations. J Pediatr Surg 2003; 38:1770-4. [PMID: 14666464 DOI: 10.1016/j.jpedsurg.2003.08.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE The aim of this study was to describe laparoscopically assisted anorectovaginoplasty (LAARVP) for the repair of selected types of female anorectal malformation. METHODS Five cases (case 1, rectovaginal fistula with a high rectum; case 2, rectovestibular fistula with double vagina; case 3, rectovestibular fistula with absent vagina; case 4, anovestibular fistula with absent vagina; case 5, cloaca) were reviewed. RESULTS Patient 4 had undergone a posterior sagittal anorectoplasty without vaginoplasty at another hospital after misdiagnosis of simple anovestibular fistula. Mean age at LAARVP was 15.4 months. At LAARVP, the fistula was divided in cases 1 through 4 and dissected as low as possible in case 5. In cases 3 and 4, the distal fistula was used to create the neovagina. In cases 1 through 3, the proximal rectum was mobilized and brought through the pelvic floor sphincter muscles using Georgeson's laparoscopically assisted colon pull-through technique through a minimal perineal incision. A posterior sagittal incision was required in cases 4 and 5. However, the initial laparoscopic approach was very helpful in both cases. Currently, all patients are well after a mean follow-up period of 32.2 months. Mean current age is 4.0 years. Patients 1 through 3 are continent, patient 4 is incontinent with soiling, and patient 5 is too young to be evaluated. CONCLUSIONS LAARVP helps to achieve low dissection of the fistula, gives optimal view of the pelvic organs, provides accurate placement of the anorectal pull-through, and minimizes abdominal perineal scars.
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Affiliation(s)
- Eri Tei
- Department of Pediatric Surgery, Juntendo University School of Medicine, Tokyo, Japan
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Yamataka A, Yoshida R, Koga H, Kobayashi H, Lane GJ, Segawa O, Kameoka S, Miyano T. Intraoperative Endosonographic Assessment of Pelvic Floor Muscles during Laparoscopy-Assisted Colon Pull-through for High Imperforate Anus. ACTA ACUST UNITED AC 2003. [DOI: 10.1089/109264103322381636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Yamataka A, Yoshida R, Kobayashi H, Lane GJ, Kurosaki Y, Segawa O, Kameoka S, Miyano T. Intraoperative endosonography enhances laparoscopy-assisted colon pull-through for high imperforate anus. J Pediatr Surg 2002; 37:1657-60. [PMID: 12483622 DOI: 10.1053/jpsu.2002.36683] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The authors used ultrasonographic endoprobes during laparoscopy-assisted colon pull-through (LACPT) for the repair of high imperforate anus to confirm the pull-through canal was surrounded symmetrically by pelvic floor muscles. METHODS Six patients with high imperforate anus were treated by LACPT (mean age at LACPT, 8.2 months). An endoscopic (12-MHz, 2.5-mm in diameter) and proctoscopic (7.5-MHz, 12-mm in diameter) probe were inserted into the proposed route of dissection intraoperatively to measure the thickness of the surrounding muscle tissue at at least 3 levels: the external anal sphincter, the levator ani muscle sling, and the intervening muscle complex. RESULTS The average thickness of the external anal sphincter was 2.3 +/- 0.4 mm anteriorly, 2.4 +/- 0.4 mm on the left, 2.4 +/- 0.5 mm posteriorly, and 2.6 +/- 0.6 mm on the right. The average thickness of the muscle complex was 2.3 +/- 0.6 mm anteriorly, 2.2 +/- 0.5 mm on the left, 2.1 +/- 0.4 mm posteriorly, and 2.2 +/- 0.5 mm on the right. The average thickness of the left crus of the levator ani muscle was 1.8 +/- 0.3 mm, the right crus was 1.9 +/- 0.4 mm, and the rim located posterior to the rectum was 2.0 +/- 0.3 mm. No statistically significant difference was found between the measurements taken at each level. CONCLUSION Intraoperative endosonography during LACPT can greatly enhance the precision of positioning the pull-through canal.
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Affiliation(s)
- Atsuyuki Yamataka
- Departments of Pediatric Surgery and Radiology, Juntendo University School of Medicine, Tokyo Women's Medical University, Tokyo, Japan
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Abstract
Numerous laparoscopic operations have replaced the traditional open procedure in both adults and children. These new procedures have allowed access to body cavities without significantly traumatizing intervening tissue. The laparoscopically assisted anorectal pull-through (LAARP) for high anorectal malformations (ARM) uses fundamental concepts learned from decades of high ARM repair and incorporates modern technologic advancements in surgical instrumentation and techniques. This laparoscopic approach offers good visualization of an infant's deep pelvis with a reconstruction technique that minimizes trauma to important surrounding structures. The laparoscopic repair can be completed in one stage, 2 stages, or 3 stages. Currently, either the 2-stage or 3-stage operation is recommended. With the 3-stage approach, a temporary colostomy is created initially followed by LAARP in several weeks to months. The colostomy then is closed several months later.
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Affiliation(s)
- Roman M Sydorak
- Department of Pediatric Surgery, University of California, San Francisco 94143, USA
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Affiliation(s)
- Jean-Martin Laberge
- Division of Pediatric General Surgery, The Montreal Children's Hospital, McGill University Health Center, Quebec, Canada
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