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Laparoscopic Assisted Pull-Through for Complex Anorectal Malformations and Cloacal Conditions
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The basic principles of the posterior sagittal anorectoplasty (PSARP) for the repair of anorectal malformations (ARMs) hold true regardless of the surgical approach. The major advantage of the laparoscopic-assisted anorectoplasty (LAARP) approach is improved visualization of the anatomy, a reduced abdominal and perineal surgical incision length, and avoidance of midline division of the levator muscle complex.
Prior to the selection of the surgical approach, all children born with an ARM require accurate assessment of the anomaly as classified utilizing the Krikenberg classification. The classification assists with ARM reconstructive options as well as guiding discussion of functional clinical outcomes. Workup for associated anomalies includes renal, spine, and cardiac assessment and a search for any additional congenital anomalies (esophageal atresia, duodenal atresia, limb anomalies, etc.). Documentation of the original ARM, the congenital lumbosacral anomalies, and the sacral ratio is important to guide discussions of fecal continence and functional prognosis.
Operative planning and management require imaging to correctly identify the level of the rectum, which guides the surgical approach. The high-pressure distal colostogram can help guide the surgical approach (PSARP vs. LAARP) based on the location of the rectum above or below the pubococcygeal (PC) line. If the rectum is the first structure encountered from the posterior sagittal approach, more success utilizing the posterior-only PSARP approach is likely ( Fig. 16-1 ). During operative construction of the neoanus, frequent use of the muscle stimulator helps identify the muscles and results in correct placement of the neorectum within the sphincter muscle complex. In males, management of a rectourethral fistula requires flush ligation with the urethra to avoid a retained remnant of the original fistula (ROOF). Finally, long-term follow-up and bowel management are required for optimal results.
The pubococcygeal line (PC line) (blue line) may be useful in predicting the need for laparoscopy or laparotomy at the time of posterior sagittal anorectoplasty. If the rectum is the first structure encountered from a posterior sagittal approach, then the operation can likely be performed using only a posterior sagittal approach. If the urinary tract is the first structure that would be encountered via a posterior sagittal incision, then it is more likely that laparoscopy or laparotomy is advantageous. A, Colostogram showing the best approach to be the posterior sagittal anorectoplasty (PSARP) technique. B, This baby has a high rectum appropriate for a laparoscopic approach.
Reproduced with permission from Halleran DR, Ahmad H, Bates DG, et al: A call to ARMs: Accurate identification of the anatomy of the rectourethral fistula in anorectal malformations. J Pediatr Surg 54:1708-1710, 2019.
Indications for Workup and Operation
Indications for the Use of Laparoscopy in Anorectal Malformations
Utilization of laparoscopy for ARMs is most clearly advantageous when the abdominal cavity requires entry. Malformations that require entry into the abdominal cavity include repair of a rectobladder-neck fistula, a high rectoprostatic fistula, a true rectovaginal fistula, and a high rectum in a cloacal malformation, or for planned inspection of Mullerian structures.
Controversial Indications
Much of the controversy in the surgical approach to ARM repair utilizing laparoscopy centers on repair of the male with an ARM and rectourethral fistula. In this malformation, preoperative imaging with a high-pressure distal colostogram often reveals that the malformation can be most reliably managed using the posterior sagittal approach. When the rectourethral fistula malformation is approached laparoscopically, the dissection poses difficulties as the common wall between the rectum and urethra is long. When the tapered rectum is not dissected flush with the urethra, the result is the premature ligation of the rectum and a ROOF (remnant of the original fistula). A retained ROOF is one of the most common complications when utilizing the LAARP technique for repair of an ARM and rectourethral fistula.
Laparoscopy also is helpful in the surgical approach for females with cloacal malformations, both at the time of operative repair and for additional evaluation of this patient group after puberty. In the neonatal period, a hydrocolpos can be drained utilizing laparoscopy when indicated at the time of colostomy creation. Laparoscopy can also be utilized during primary cloacal repair for mobilization of a high rectum in combination with a PSARP approach. In postpubertal females with previously reconstructed cloacal anomalies, laparoscopy can assist with assessment and treatment of hematometra and obstructed uterine horns. In patients with surgical reconstructions such as bladder augmentation with an umbilical Mitrofanoff and/or right lower quadrant appendicostomy, the use of laparoscopy using a lateral approach and the visualizing trocar/cannula or Veress needle access helps avoid damage to these lower abdominal midline reconstructions.
Operative Technique
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