Laparoscopic Assisted Posterior Sagittal Anorectoplasty

The location of the intended anoplasty in males with anorectal malformation is marked by discoloration in the area of the sphincteric ellipse.

Rectourinary fistulas are classified by their entry point into the urinary tract: bladder neck fistulas enter the deltoid/shoulder region of the urethra, prostatic fistulas enter the triceps/humerus area, and bulbar fistulas enter at the elbow of the urethra.

Laparoscopic view alone does not help the surgeon know where the distal rectum enters the urinary tract.

A properly done distal colostogram is required to determine where the distal rectum enters the urinary tract.

Cases with high rectum and fistula to the lower prostatic level, where the rectum is above the pubococcygeal (PC) line, are amenable to a laparoscopic approach.

Cases with lower rectum and fistula to the bulbar urethra are ideal for a posterior sagittal approach.

For laparoscopic-assisted PSAP in high rectoprostatic fistula, a 5mm port is placed at the umbilicus for the camera, then moved to the right upper quadrant for best pelvic visualization, with the umbilical port becoming the surgeon's left hand instrument.

Additional ports are placed in the left upper quadrant for the assistant and right lower quadrant for the surgeon's right hand instrument.

The sphincter extent is defined using an electrical stimulator and marked with silk sutures before muscle relaxant is administered.

Laparoscopic dissection of the distal rectum stays intimately attached to the rectal wall, preserving the inferior mesenteric artery (IMA) and its arcade.

The intramural blood supply that perfuses the rectal wall is visible during dissection.

Redundancy in the sigmoid indicates the colostomy was correctly opened in the proximal sigmoid, leaving the distal aspect for the pull-through.

Circumferential dissection continues until the rectum tapers into a narrow fistula, with the goal of having the tapered area be the size of a 3mm Maryland grasper.

Dissection extends up to the stoma to free the rectum so the pull-through will not be under tension.

Before ligating the fistula, the perineum is opened at the intended location of the anoplasty to create the pathway into the pelvis for the pull-through.

The fistula is ligated by preloading a Maryland grasper over an endoloop.

The distal rectum is cut with sharp scissors, allowing the urinary tract to be closed with the endoloop.

The anoplasty is created by tacking the posterior rectal wall to the edge of the muscle complex.