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Laparoscopic Assisted Anorectal Pull-through. Keith Georgeson Professor of Surgery University of Alabama School of Medicine. Pre-operative Evaluation. Proximal sigmoid colostomy Careful perineal evaluation Distal colostogram under pressure X-rays of spine and pelvis.

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laparoscopic assisted anorectal pull through

Laparoscopic Assisted Anorectal Pull-through

Keith Georgeson

Professor of Surgery

University of Alabama School of Medicine

pre operative evaluation
Pre-operative Evaluation
  • Proximal sigmoid colostomy
  • Careful perineal evaluation
  • Distal colostogram under pressure
  • X-rays of spine and pelvis
indications for surgery
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
patient positioning
Patient Positioning
  • Supine
  • Cross table
  • End of table
  • Body but not head elevated on sheets
  • Firmly taped in position
equipment
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
laarp
LAARP

Technique

goals of lap assisted anorectal pull through
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
slide8

Bladder

Colon

Anorectal Malformations

laparoscopic pull through1

Bladder

Clip

Rectum

Laparoscopic Pull-through

Recto-Urethral Fistula

elements for fecal continence
Internal sphincter competence

Rectal reservoir

Anorectal angle

Rectosigmoid motility

Elementsfor Fecal Continence
elements for fecal continence1
Elements for Fecal Continence
  • Sensation of rectal distention
  • Anoderm anal-lined canal
  • Anorectal reflex
  • External sphincter competence
  • Stool consistency
psarp
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

anorectal function after posterior sagital anorectoplasty
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

anorectal malformations
Anorectal Malformations

Eventual continence is related to a positive anorectal reflex

Tsuji et al, JPS 37,2002

positive arr
Positive ARR

LARPSARP

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

P = 0.0001

Lin, et al

lap assisted pull through time to develop arr
Lap Assisted Pull-throughTime to Develop ARR

LAPPSARP

4.9 + 1.2 months 10.1 + 2.5 months

Lin, et al

laparoscopic primary pullthrough for hirschsprung s disease
Laparoscopic Primary Pullthrough for Hirschsprung’s disease

Conventional Laparoscopicstaged pullthrough primary pullthrough

mid term analysis for high anorectal malformations
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
laparoscopic pull through3
Laparoscopic Pull-through

Surgical Anal Canal

lap assisted pull through complications
Lap-Assisted Pull-ThroughComplications
  • Urethral perforation
  • Diverticulum around fistular clip
  • Rectal prolapse
  • Missed muscle complex
tips tricks
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
laparoscopic pull through postoperative management
Laparoscopic Pull-throughPostoperative Management
  • Fed on first or second post-operative day
  • Graduated anorectal dilation started in two weeks
  • Colostomy closure in three months
goals of lap assisted anorectal pull through1
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
lap assisted pull through
Lap Assisted Pull-through
  • Anatomically sound
  • Leaves muscles intact
  • Higher incidence of ARR
  • Better rectal compliance
  • Needs long term follow-up