Laparoscopy and its use in the repair of anorectal malformations.
ABSTRACT Laparoscopy has been used for the treatment of anorectal malformations (ARMs) in an attempt to be less invasive and with the hope that it would result in a better functional outcome. There remains a significant debate about whether these expectations have been fulfilled.
Seventeen patients with ARM for whom laparoscopy was used were retrospectively reviewed. Six were operated on primarily by the authors, and 11 cases were referred after a laparoscopic repair performed elsewhere. In addition, a literature review was performed looking for evidence of less invasiveness and improved functional results in patients operated on laparoscopically.
The diagnosis was imperforate anus with a rectobladder neck fistula in our 6 cases with the fistula ligated laparoscopically in each case. In 1 patient, the malformation was repaired entirely using laparoscopic technique. The other 5 patients had a laparoscopically assisted repair because we had to open the abdomen to taper a dilated rectum in 2, mobilize a very high rectum in 2, and take down a distal colostomy stoma in 1. Eleven patients were referred with a variety of problems after a laparoscopic repair done elsewhere for rectal stricture (5), rectal prolapse (4), recurrent rectourethral fistula (3), rectal mislocation (3), failed attempted repair leading to fecal incontinence (1), and a posterior urethral diverticulum (1). Our literature review included 47 references (involving 323 patients) published between 1998 and 2010. All studies showed that laparoscopic repair of ARMs is feasible. The review, however, did not provide evidence of less invasiveness or improved functional results.
Laparoscopy for ARM is a less invasive procedure when compared with those operations that would have previously required a laparotomy (rectobladder neck fistula). In cases of rectoprostatic fistulae, the laparoscopic approach is feasible and avoids a lengthy posterior sagittal incision. There is no evidence that the laparoscopic approach is a less invasive procedure for other types of ARMs. In cases of rectobulbar fistula, congenital anal stenosis, perineal fistula, ARM without fistula, the evidence suggests that it may be lead to more complications. There is no evidence in the literature demonstrating better functional results in cases of ARM operated on laparoscopically.
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ABSTRACT: BACKGROUND: Anorectal malformation is a complex anomaly with a broad variety of expressions. There are different techniques available for correction of the anomaly, all with their specific morbidity. Recently, much attention has been paid to acquired posterior urethral diverticulum after correction of anorectal malformation. The aim of this retrospective study was to reappraise the laparoscopic approach to correction of the anorectal malformation with respect to what can be prevented and what can be improved. METHODS: Between July 2000 and July 2011, a total of 19 boys born with a high or intermediate anorectal malformation were admitted to our center. All patients underwent a diagnostic workup and were included in the follow-up protocol. Follow-up continence was scored according to the Krickenbeck criteria. Patients were also invited for an ultrasound and micturition cystourethrogram (MCUG) at follow-up to determine or exclude the presence of a posterior urethral diverticulum. RESULTS: All patients underwent a successful laparoscopy-assisted anorectal pull-through. Mean age at the time of surgery was 2.5 months. Mean length of hospital stay was 5 days. Mean follow-up was 73 months. Complications were encountered in six patients. At follow-up 53 % of all our patients had spontaneous bowel movements and 41 % needed the help of laxatives or rectal washouts. In three patients a residual blind ending fistula was determined on MCUG but there was no true diverticulum. CONCLUSION: Correction of anorectal malformation is a complex procedure with significant morbidity. Refinements of the technique may prevent complications and improve outcome in both the laparoscopic and posterior sagittal anorectoplasty. Acquired posterior urethral diverticulum does not necessarily need to occur more often with the laparoscopic approach.World Journal of Surgery 03/2013; · 2.36 Impact Factor