Laparoscopic Assisted Posterior Sagittal Anorectoplasty

Laparoscopic assisted posterior sagittal anorectoplasty. In this video, we present a case of a laparoscopic assisted PSAP for a patient with an anorectal malformation and a high recoprostatic fistula. Here is a typical perineum of a male with an anorectal malformation. The location of the intended anoplasty is obvious, with a discoloration in the area of the sphincteric ellipse. Remember the schema of determining the location of the distal rectum relative to the urinary tract as imposed on the elbow of this Rodin statue. If the fistula enters the deltoid or shoulder region of the urethra, it is a bladder neck fistula. If it enters the triceps or humerus area, it is a prostatic fistula. And if it enters at the elbow of the urethra, it is a bulbar fistula. Here are representative distal callostrograms of a recoprostatic fistula on the left and erectile bladder neck fistula on the right. The laparoscopic view alone does not help the surgeon know where the distal rectum enters the urinary tract. This requires a properly done distal callostogram. The image on the top right shows a high rectum, with a fistula to the lower prostatic level. This kind of case is amenable to a laparoscopic approach, as the rectum is above the pubococcygeal or PC line. The image on the bottom right shows a lower rectum with a fistula to the bulbar urethra. This case is ideal for a posterior sagittal approach. In our case today, the laparoscopic setup for a high recoprostatic fistula uses a 5 millimeter port at the umbilicus for the camera, which is then moved to the right upper quadrant for best visualization of the pelvis. The umbilical port then becomes the instrument for the surgeon's left hand. A left upper quadrant port is for the assistant, and the right lower quadrant port is for the surgeon's right hand instrument. A total body prep is performed and a Foley catheter inserted. The legs are then lifted up and the sphincter marked with silk sutures after we have defined its extent using an electrical stimulator. Now, once the sphincter has been marked, the anesthesiologist can provide muscle relaxant with the patient in supine position. 4 ports are inserted for dissection of the deep pelvis. The laparoscopic dissection of the distal rectum begins. The dissection stays intimately attached to the rectal wall, preserving the IMA in its arcade. You can see the intramural blood supply well, which profuses the rectal wall. There appears to be plenty of redundancy in the sigmoid, meaning the colostomy was correctly opened in the proximal sigmoid, leaving the distal aspect for the pull through. The dissection continues circumferentially around the distal rectum. We keep dissecting until the rectum tapers into a narrow fistula. Our goal is to have this tapered area be the size of a 3 millimeter Maryland grasper. We dissect up to the stoma to free the rectum so the pull through will not be under any tension. And now we check that the rectum will easily reach the perineum. Now before ligating the fistula we open the perineum just at the intended location of the anoplasty. With blunt, gentle dissection, we find the path into the pelvis which will be the trajectory of the pull through. We see that the fistula tissue is smaller than the Maryland. Now we ligate the fistula by preloading the Maryland over an endo loop. And now we cut the distal rectum with sharp scissors and therefore can close the urinary tract with the endo loop. Here you see the pull-through of the distal rectum through our previously created pathway. And we ensure that the pull through is straight. We grasp the distal rectum with a suture. And can now create the anoplasty with tacking of the posterior rectal wall to the edge of the muscle complex.