Recto-Bladderneck Fistula: Laparoscopic-Assisted Anorectoplasty

A high rectal bladder neck fistula connected to the bladder is not reachable safely from a posterior sagittal approach alone

Port placement for laparoscopic anorectal malformation repair uses umbilical access, 4mm trocars in right upper quadrant (camera) and right mid abdomen (surgeon's right hand), with umbilicus for surgeon's left hand

Fixing the bladder to the anterior abdominal wall with a transcutaneous stay suture provides better exposure of the pelvis during laparoscopic anorectal malformation repair

Circumferential mobilization of the distal rectum should start with anterior attachments, work laterally, then release posterior attachments

Both ureters and vas deferens must be identified and avoided during rectal mobilization in anorectal malformation repair

A 3mm endosealer should be used for attachments near the bladder to avoid thermal spread during rectal mobilization

The inferior mesenteric artery and its branches must be preserved as they provide intramural blood supply to the distal rectum

The fistula should be divided at the point of maximal tapering of the distal rectum near the bladder

The bladder side of the divided fistula can be closed with a grasper and a preloaded endo loop

Adequate rectal length must be gained to perform anorectoplasty without tension

Prone positioning is not necessary for the posterior sagittal portion of laparoscopic-assisted anorectoplasty; the patient's legs can simply be positioned up

A nerve stimulator should be used to identify the muscle complex before making the posterior sagittal incision

A limited posterior sagittal incision allows for safer passage into the pelvis and permits tacking of the rectum to the posterior edge of the sphincter complex

Blunt dissection is used to create a space between the sacrum and the pubis for passage of the rectum

The rectum should be placed within the center of the sphincter complex and anchored to the posterior aspect of the sphincter

Anorectoplasty for this procedure uses 16 sutures