Laparoscopic assisted anorectal pull through: Reformed techniques

Abstract

Aim:To assess the modifications in the technique of laparoscopic assisted anorectal pull through (LAARP) practiced at our institute and analyze the post operative outcome and associated complications.Materials and Methods:A retrospective study from January 2001 to May 2009 analyzing LAARP for high anorectal malformations.Results:A total of 40 patients - 34 males and six females, in the age group of two months to six years were studied. Staged procedure was done in 39 patients; one child with recto vestibular fistula underwent single stage procedure. All the patients withstood surgery well. One patient required conversion due to problems in gaining enough length for the distal rectum in a patient with rectovesical fistula so colostomy was closed and re-located at a proximal splenic flexure. The complications were mucosal prolapse (six cases), anal stenosis (three), adhesive obstruction (two), distal rectal necrosis (one), and urethral diverticulum (one). The patients were followed up with clinical evaluation and continence scoring. The progress has been satisfactory and weight-gain is adequate.Conclusions:The advantages of the reformed techniques are as follows: Transcutaneous bladder stitch provides excellent visualization; traction over the fistula helps in dissection of the puborectalis, dividing the fistula without ligation is safe, railroading of Hegar's dilators over the suction canula creates adequate pull through channel, saves time and makes procedure simpler with reproducible comparable reports.

Postoperative “complications" following laparoscopic-assisted anorectoplasty: A systematic review

“…The tunnel formation in LAARP was done under laparoscopic visualization and perineal muscle electrostimulation with or without laparoscopic muscle electrostimulation. The perineal dissection was done either bluntly using artery forceps or needle was placed in the center of the muscle complex, followed by balloon catheter dilation [4,6,10,11, Step Veress needle with a radially expanding sheet was another technique used to create the tunnel [12,14].…”

Institutional experience with laparoscopic-assisted anorectal pull-through in a series of 17 cases: A retrospective analysis

“…[ 7 ] Anchoring the rectum with pre-sacral fascia is believed to prevent RMP in addition to lengthening of cutaneous anal canal by providing cephalad retraction, although some studies did not perceive that benefit. [ 3 7 ] In our initial three cases, we did not do presacral fixation and there was higher incidence of mucosal prolapse. Then, we believed in rectal fixation in all the remaining cases.…”

“…When compared to APPT, LAARP provides benefits such as avoidance of laparotomy, excellent visualisation of pelvis, less post-operative pain and simultaneous treatment of associated disease like cryptorchidism. [ 3 ] Although the long-term results of LAARP are yet to be interpreted, mid-term results from a study showed better defecation function with LAARP than PSARP. [ 4 ] LAARP results in earlier appearance of recto anal inhibitory reflex than PSARP.…”

“…Urethral diverticulum has been reported in some series and as explained by difficult and inadequate mobilisation at the fistulous site in cases of recto-bulbar urethral fistulae. [ 3 7 ] We did not come across this complication since our series excluded the cases of intermediate ARM. Post-operative adhesive obstruction due to intra-operative spillage of contents from rectal stump (barium) has been reported.…”

“…Post-operative adhesive obstruction due to intra-operative spillage of contents from rectal stump (barium) has been reported. [ 3 ] This can be avoided by proper distal loop wash before LAARP.…”