Laparoscopic Laparoscopic Assisted Assisted

Anorectal Pull-Anorectal Pull-throughthroughKeith GeorgesonKeith Georgeson

Professor of SurgeryProfessor of Surgery

University of Alabama School of University of Alabama School of MedicineMedicine

Pre-operative EvaluationPre-operative Evaluation

Proximal sigmoid colostomyProximal sigmoid colostomy Careful perineal evaluationCareful perineal evaluation Distal colostogram under pressureDistal colostogram under pressure X-rays of spine and pelvisX-rays of spine and pelvis

Indications for SurgeryIndications for Surgery

All patients with high anorectal All patients with high anorectal malformationsmalformations

Some patients with intermediate Some patients with intermediate ARMsARMs

No patients with low ARMsNo patients with low ARMs Newborn patients if level can be Newborn patients if level can be

determineddetermined

Patient PositioningPatient Positioning

Supine Supine Cross tableCross table End of tableEnd of table Body but not head elevated on Body but not head elevated on

sheetssheets Firmly taped in positionFirmly taped in position

EquipmentEquipment One 5mm trocar, two 4mm trocarsOne 5mm trocar, two 4mm trocars Hook cautery-3mmHook cautery-3mm Bowel grasper-3mmBowel grasper-3mm Scissors-3mmScissors-3mm Needle driver-3mmNeedle driver-3mm Large monofilament sutureLarge monofilament suture Loop ligature-2Loop ligature-2 Sleeved, Varess needle trocars (inserts Sleeved, Varess needle trocars (inserts

5,10,12)5,10,12) Open minor instrument trayOpen minor instrument tray

LAARPLAARP

TechniqueTechnique

Goals of Lap-Assisted Goals of Lap-Assisted Anorectal Pull-ThroughAnorectal Pull-Through

Avoid dividing and weakening Avoid dividing and weakening external sphinctersexternal sphincters

Precise placement of rectum Precise placement of rectum through external sphinctersthrough external sphincters

Diminish perirectal scarringDiminish perirectal scarring Potential development of primary Potential development of primary

procedure avoiding colostomyprocedure avoiding colostomy

ColonColon

BladderBladder

Anorectal MalformationsAnorectal Malformations

VasVas

UreterUreter

Laparoscopic Pull-throughLaparoscopic Pull-through

RectumRectum

BladderBladder

ClipClip

Laparoscopic Pull-throughLaparoscopic Pull-through

Recto-Urethral FistulaRecto-Urethral Fistula

Laparoscopic Pull-throughLaparoscopic Pull-through

Alternative ApproachesAlternative Approaches

Elements for Fecal Continence

Internal sphincter competenceInternal sphincter competence

Rectal reservoirRectal reservoir

Anorectal angleAnorectal angle

Rectosigmoid motilityRectosigmoid motility

Elements for Fecal Elements for Fecal ContinenceContinence

Sensation of rectal distentionSensation of rectal distention

Anoderm anal-lined canalAnoderm anal-lined canal

Anorectal reflexAnorectal reflex

External sphincter competenceExternal sphincter competence

Stool consistencyStool consistency

PSARPPSARP

PSARP does not provide superior PSARP does not provide superior fecal continence when compared to fecal continence when compared to other pull-through operations for high other pull-through operations for high imperforate anusimperforate anus

Nulder, et alNulder, et al EJPS EJPS19951995

Bliss, Tapper, et alBliss, Tapper, et al JPS JPS 19961996

ShandlingShandling JPSJPS 19961996

Anorectal Function after Anorectal Function after Posterior Sagital Posterior Sagital AnorectoplastyAnorectoplasty

Better anatomical positioning than Better anatomical positioning than older conventional operationsolder conventional operations

Increased constipationIncreased constipation Manometry is similarManometry is similar Long-term function is similarLong-term function is similar Most patients need bowel Most patients need bowel

managementmanagementTsuji et al, JPS Tsuji et al, JPS

37,200237,2002

Anorectal MalformationsAnorectal Malformations

Eventual continence is related to Eventual continence is related to a positive anorectal reflexa positive anorectal reflex

Tsuji et al, JPS 37,2002Tsuji et al, JPS 37,2002

Positive ARRPositive ARR

LARLAR PSARPPSARP

8/9 = 89%8/9 = 89% 4/13 = 30.8%4/13 = 30.8%

P = 0.0001P = 0.0001

Lin, et alLin, et al

Lap Assisted Pull-throughLap Assisted Pull-throughTime to Develop ARRTime to Develop ARR

LAPLAP PSARPPSARP4.9 4.9 ++ 1.2 months 1.2 months 10.1 10.1 ++ 2.5 months 2.5 months

Lin, et alLin, et al

Laparoscopic Primary Laparoscopic Primary Pullthrough for Pullthrough for

Hirschsprung’s diseaseHirschsprung’s disease

ConventionalConventional LaparoscopicLaparoscopicstaged pullthroughstaged pullthroughprimary pullthroughprimary pullthrough

Mid-term Analysis for High Mid-term Analysis for High Anorectal MalformationsAnorectal Malformations

No difference in centrality of pull-No difference in centrality of pull-through between Pena and through between Pena and GeorgesonGeorgeson

Muscle groups similarMuscle groups similar Continence somewhat better in G Continence somewhat better in G

groupgroup G=15, P=9G=15, P=9

Laparoscopic Pull-throughLaparoscopic Pull-through

Surgical Anal CanalSurgical Anal Canal

Lap-Assisted Pull-ThroughLap-Assisted Pull-Through ComplicationsComplications

Urethral perforation Urethral perforation

Diverticulum around fistular clipDiverticulum around fistular clip

Rectal prolapseRectal prolapse

Missed muscle complexMissed muscle complex

Tips/TricksTips/Tricks

Hitch the bladder wall with a U-stitchHitch the bladder wall with a U-stitch Convergence of the vas deferens visually Convergence of the vas deferens visually

guides the surgeon to the prostateguides the surgeon to the prostate Don’t repair small nicks in the smooth muscleDon’t repair small nicks in the smooth muscle Open the rectal fistula to confirm it’s junction Open the rectal fistula to confirm it’s junction

with the urethrawith the urethra Push the plastic guide of the loop ligature to Push the plastic guide of the loop ligature to

the distal side of the rectourethral fistulathe distal side of the rectourethral fistula The anorectal angle is straight with the The anorectal angle is straight with the

thighs flexedthighs flexed

Fed on first or second post-operative Fed on first or second post-operative

dayday

Graduated anorectal dilation started Graduated anorectal dilation started

in two weeksin two weeks

Colostomy closure in three monthsColostomy closure in three months

Laparoscopic Pull-throughLaparoscopic Pull-through

Postoperative ManagementPostoperative Management

Goals of Lap-Assisted Goals of Lap-Assisted Anorectal Pull-ThroughAnorectal Pull-Through

Avoid dividing and weakening Avoid dividing and weakening external sphinctersexternal sphincters

Precise placement of rectum Precise placement of rectum through external sphinctersthrough external sphincters

Diminish perirectal scarringDiminish perirectal scarring Potential development of primary Potential development of primary

procedure avoiding colostomyprocedure avoiding colostomy

Lap Assisted Pull-throughLap Assisted Pull-through

Anatomically soundAnatomically sound

Leaves muscles intactLeaves muscles intact

Higher incidence of ARRHigher incidence of ARR

Better rectal complianceBetter rectal compliance

Needs long term follow-upNeeds long term follow-up