JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 19, Number S1, 2009 © Mary Ann Liebert, Inc. DOI: 10.1089/lap.2008.0157.supp
Transperineal Rectovesical Fistula Ligation in Laparoscopic-Assisted Abdominoperineal Pull-Through for High Anorectal Malformations Sameh Abdel Hay, MD
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. Introduction
anorectal malformation with rectovesical or rectoprostatic fistula by retrospective review of the medical record after approval from the research committee.
M
ANY TECHNIQUES HAVE BEEN DESCRIBED for dissection and separation of rectovesical fistula or rectoprostatic fistula during laparoscopy. This entails clip application,1 endoloop application after division of the fistula,2 or suture ligation. An alternative simple technique for ligation of the fistula will be described.
Technique With the patient in the lithotomy position, the abdomen and perineum were cleaned and draped to allow simultaneous abdominal and perineal exposure.
Materials and Methods
Abdominal part
Over the last 5 years, laparoscopic-assisted abdominoperineal pull-through was performed in 12 boys with high
Three ports were used for mobilization of the fistula, one 5 mm in the umbilicus for the laparoscope and two addi-
Pediatric Surgery Unit, Ain Shams University, Cairo, Egypt.
1
2
ABDEL HAY ineum at the site of neo anus. Once the fistula was well dissected all around, the plane behind the fistula was entered with blunt dissection to expose the puborectalis muscle from above. Perineal part
FIG. 1. Grasping the passed ligature from the perineum with Maryland forceps.
tional 3-mm ports for working instruments (one in the right iliac fossa and the other in the left hypochondrium). Initial evaluation for the site of colostomy was performed to ensure the presence of adequate length for the rectum to be mobilized and pulled to the perineum if the colostomy was cited at the distal end of the sigmoid leading to short distal loop. The dissection started at the junction of the fistula with the urinary bladder, cutting of the peritoneum in front, on the right then on the left side, defining the important surrounding structure: seminal vesicle and the ureters. The dissection was completed aiming to turn around the fistula and proceed distally to reach its narrowest part and proximally to get enough length of the rectum to be brought to the per-
FIG. 2. The ligature regrasped with the perineal clamp after forming a loop around the fistula.
The center of the external anal sphincter was identified using a muscle stimulator. A 2-cm incision was performed in the center and deepened for 1 cm. A Hegar dilator (No. 2) introduced through the center of the anal sphincter emerged in the center of the puborectalis sling in the midline just behind the fistula as seen by laparoscopy. The tract was dilated progressively with Hegar dilators till reaching a suitable size for rectal pull-through. A 10-mm cannula with a blunt trocar was introduced along the tract, through which a Maryland forceps holding vicryl (2-0) ligature was passed through the perineal incision across the dilated tract to emerge on the right side of the fistula (Fig. 1), then grasped through the abdomen and turned anterior to the junction of the fistula with the bladder forming a loop and regrasped from the left side with the perineal clamp and brought to the outside (Fig. 2). The two ends of the ligature forming a loop around the fistula and emerging from the perineal site were tied and the knot was pushed using the finger (Fig. 3). The fistula was cut laparoscopically, and with the help of a Babcock forceps, the mobilized rectum was pulled through the perineal incision to be sutured at the site of the future anus. Results Twelve patients with high anorectal malformation with recto bladder neck fistula had their fistulas ligated with this technique. Their age ranged from 3 to 9 months. Ligation of the fistula was possible in all patients using this technique with no conversion or intraoperative mishaps. Operative time ranged from 90 to 120 minutes (mean 110 minutes). Ascending urethrogram showed no residual diverticulum in all
FIG. 3.
Tying of the ligature from the perineal site.
FISTULA LIGATION IN HIGH ANORECTAL MALFORMATIONS but one patient, who showed residual diverticulum that presented with difficulty in micturation and needed to be excised by open surgery. Follow-up of these boys ranged from 6 months to 5 years. One patient developed mucosal prolapse that was corrected surgically. Ten out of 12 patients are continent to stools but all had initial constipation that disappeared with time. Magnetic resonance imaging was done in six patients and showed proper location of the rectum in the center of the muscle complex. Discussion When laparoscopy was introduced, it became very obvious that a small group of patients who required laparotomy could potentially benefit from laparoscopy, thereby avoiding opening of the abdominal wall. In our opinion, only rectovesical or rectoprostatic fistula should be approached with this technique because the lower fistula can be managed though the posterior sagittal approach without the need to go through the abdomen. After initial mobilization of the rectum, till reaching the rectovesical or rectoprostatic fistula, ligation division of the fistula is the next step, followed by creation of a tract through the muscle complex through which the mobilized rectum can be brought to the perineum. Many techniques were used for identification of the center of the muscle complex where the rectum should be placed.3–5 Creation of the pathway for the mobilized rectum in the muscle complex entails passing a Veress needle from the center of the external sphincter that carries a dilatable cannula used for the pull-through procedure.1,2 The use of a sharp cannula for this step carries the risk of injury of the urethra/seminal vesicle and the ureters. Others used blunt hemostat guided by ultrasonography,4 which helped to avoid urethral injury and ensured proper localization of the center of the muscle complex. We used a Hegar dilator with rounded blunt end for creation of the pathway in the center of the muscle complex to avoid injury to surrounding important structures. In the described technique, cutting of the fistula was delayed till the puborectalis sling was identified and the tract through the muscle complex was created, and we used the fistula site as guide for the center of muscle complex. Passing a Hegar dilator from the perineal incision guided by laparoscopy to emerge just behind the site of the fistula had three advantages: 1. The blind end of the Hegar dilator is not traumatic for the surrounding structure (urethra, seminal vesicle, and ureters), unlike the Veress needle used for insertion of the dilatable trocar. 2. The technique allows proper identification of the center of the muscle complex by passing it in the midline just behind the fistula with progressive dilatation till reaching the proper size to accommodate the pulled rectum. 3. This technique allows introduction of a vicryl ligature that loops around the fistula and is ligated from the perineal site, thus avoiding clip application that has the disadvantage of possibility of slipping, migration, and penetration to the surrounding structure. The technique also avoids intracorporeal laparoscopic suturing and ligation, which take a longer time and are more tedious.
3
Follow-up of these boys showed acceptable continence in 10 out of 12, but all initially had constipation. Rectal mucosal prolapse occurred only in one patient, which needed surgical correction. One patient developed diverticulum at the remnant of the ligated fistula. The initial urethrogram was misleading, and it was diagnosed as rectoprostatic fistula but was a rectobulbar fistula; the junction was missed during laparoscopic dissection. Excision of the diverticulum was performed by open surgery. Postoperative magnetic resonance imaging performed on six patients showed central location of the pulled rectum in the muscle complex, denoting efficacy of this technique in localizing the center of the levator ani. Conclusion Transperineal rectovesical fistula ligation in laparoscopicassisted 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. Acknowledgment I would like to thank Prof. Hesham A. Elsafoury for his help in drawing the diagrams used for description of this technique. Disclosure Statement No competing financial interests exist. References 1. Georgeson KE, Inge TH, Albanese CT. Laparoscopically assisted anorectal pull-through for high imperforate anus—a new technique. J Pediatr Surg 2000;35:927–930; discussion 930–931. 2. Sydorak RM, Albanese CT. Laparoscopic repair of high imperforate anus. Semin Pediatr Surg 2002;11:217–225. 3. Yamataka A, Segawa O, Yoshida R, Kobayashi H, Kameoka S, Miyano T. Laparoscopic muscle electrostimulation during laparoscopy-assisted anorectal pull-through for high imperforate anus. J Pediatr Surg 2001;36:1659–1661. 4. 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;40:1535–1538. 5. Iwanaka T, Arai M, Kawashima H, Kudou S, Fujishiro J, Matsui A, Imaizumi S. Findings of pelvic musculature and efficacy of laparoscopic muscle stimulator in laparoscopy-assisted anorectal pull-through for high imperforate anus. Surg Endosc 2003;17:278–281; Epub 2002 Oct 8.
Address reprint requests to: Sameh Abdel Hay, MD Pediatric Surgery Unit Ain Shams University 1 El Mokades El Kabary Street 7th District, Nasr City Cairo, Egypt E-mail:
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