Laparoscopic Assisted Anorectal Pull-through

1. Laparoscopic Assisted Anorectal Pull-through Keith Georgeson Professor of Surgery University of Alabama School of Medicine

2. Pre-operative Evaluation • Proximal sigmoid colostomy • Careful perineal evaluation • Distal colostogram under pressure • X-rays of spine and pelvis

3. 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

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

5. 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

6. LAARP Technique

7. 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

8. Bladder Colon Anorectal Malformations

10. Vas Ureter Laparoscopic Pull-through

12. Bladder Clip Rectum Laparoscopic Pull-through Recto-Urethral Fistula

21. Laparoscopic Pull-through

22. Alternative Approaches

25. Internal sphincter competence Rectal reservoir Anorectal angle Rectosigmoid motility Elementsfor Fecal Continence

26. Elements for Fecal Continence • Sensation of rectal distention • Anoderm anal-lined canal • Anorectal reflex • External sphincter competence • Stool consistency

27. 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

28. 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

31. Anorectal Malformations Eventual continence is related to a positive anorectal reflex Tsuji et al, JPS 37,2002

33. Positive ARR LARPSARP 8/9 = 89% 4/13 = 30.8% P = 0.0001 Lin, et al

34. Lap Assisted Pull-throughTime to Develop ARR LAPPSARP 4.9 + 1.2 months 10.1 + 2.5 months Lin, et al

37. Laparoscopic Primary Pullthrough for Hirschsprung’s disease Conventional Laparoscopicstaged pullthrough primary pullthrough

38. 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 • G=15, P=9

40. Laparoscopic Pull-through Surgical Anal Canal

41. Lap-Assisted Pull-ThroughComplications • Urethral perforation • Diverticulum around fistular clip • Rectal prolapse • Missed muscle complex

42. Tips/Tricks • Hitch the bladder wall with a U-stitch • Convergence of the vas deferens visually guides the surgeon to the prostate • Don’t repair small nicks in the smooth muscle • Open the rectal fistula to confirm it’s 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

43. Laparoscopic Pull-throughPostoperative Management • Fed on first or second post-operative day • Graduated anorectal dilation started in two weeks • Colostomy closure in three months

44. 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

45. Lap Assisted Pull-through • Anatomically sound • Leaves muscles intact • Higher incidence of ARR • Better rectal compliance • Needs long term follow-up