Laparoscopic Assisted Anorectal Pull-through

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Laparoscopic Assisted Anorectal Pull-through

• Keith Georgeson
• Professor of Surgery
• University of Alabama School of Medicine

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Pre-operative Evaluation

• Proximal sigmoid colostomy
• Careful perineal evaluation
• Distal colostogram under pressure
• X-rays of spine and pelvis

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Indications for Surgery

• All patients with high anorectal malformations
• Some patients with intermediate ARMs
• No patients with low ARMs
• Newborn patients if level can be determined

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Patient Positioning

• Supine
• Cross table
• End of table
• Body but not head elevated on sheets
• Firmly taped in position

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Equipment

• One 5mm trocar, two 4mm trocars
• Hook cautery-3mm
• Bowel grasper-3mm
• Scissors-3mm
• Needle driver-3mm
• Large monofilament suture
• Loop ligature-2
• Sleeved, Varess needle trocars (inserts 5,10,12)
• Open minor instrument tray

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LAARP

• Technique

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Goals of Lap-Assisted Anorectal Pull-Through

• Avoid dividing and weakening external sphincters
• Precise placement of rectum through external
  sphincters
• Diminish perirectal scarring
• Potential development of primary procedure
  avoiding colostomy

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Anorectal Malformations
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Laparoscopic Pull-through
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Laparoscopic Pull-through
Recto-Urethral Fistula
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Laparoscopic Pull-through
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Alternative Approaches
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Elements for Fecal Continence

• Internal sphincter competence
• Rectal reservoir
• Anorectal angle
• Rectosigmoid motility

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Elements for Fecal Continence

• Sensation of rectal distention
• Anoderm anal-lined canal
• Anorectal reflex
• External sphincter competence
• Stool consistency

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PSARP

• PSARP does not provide superior fecal continence
  when compared to other pull-through operations
  for high imperforate anus
• Nulder, et al EJPS 1995
• Bliss, Tapper, et al JPS 1996
• Shandling JPS 1996

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Anorectal Function after Posterior Sagital
Anorectoplasty

• Better anatomical positioning than older
  conventional operations
• Increased constipation
• Manometry is similar
• Long-term function is similar
• Most patients need bowel management
• Tsuji et al, JPS 37,2002

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Anorectal Malformations

• Eventual continence is related to a positive
  anorectal reflex
• Tsuji et al, JPS 37,2002

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Positive ARR

• LAR PSARP
• 8/9 89 4/13 30.8
• P 0.0001
• Lin, et al

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Lap Assisted Pull-throughTime to Develop ARR

• LAP PSARP
• 4.9 1.2 months 10.1 2.5 months
• 
  Lin, et al

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Laparoscopic Primary Pullthrough for
Hirschsprungs disease

• Conventional Laparoscopicstaged
  pullthrough primary pullthrough

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Mid-term Analysis for High Anorectal Malformations

• No difference in centrality of pull-through
  between Pena and Georgeson
• Muscle groups similar
• Continence somewhat better in G group
• G15, P9

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Laparoscopic Pull-through
Surgical Anal Canal
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Lap-Assisted Pull-Through Complications

• Urethral perforation
• Diverticulum around fistular clip
• Rectal prolapse
• Missed muscle complex

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Tips/Tricks

• Hitch the bladder wall with a U-stitch
• Convergence of the vas deferens visually guides
  the surgeon to the prostate
• Dont repair small nicks in the smooth muscle
• Open the rectal fistula to confirm its junction
  with the urethra
• Push the plastic guide of the loop ligature to
  the distal side of the rectourethral fistula
• The anorectal angle is straight with the thighs
  flexed

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Laparoscopic Pull-throughPostoperative Management

• Fed on first or second post-operative day
• Graduated anorectal dilation started in two weeks
• Colostomy closure in three months

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Goals of Lap-Assisted Anorectal Pull-Through

• Avoid dividing and weakening external sphincters
• Precise placement of rectum through external
  sphincters
• Diminish perirectal scarring
• Potential development of primary procedure
  avoiding colostomy

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Lap Assisted Pull-through

• Anatomically sound
• Leaves muscles intact
• Higher incidence of ARR
• Better rectal compliance
• Needs long term follow-up

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