Combined Laparoscopically Assisted and Anterior Sagittal Anorectoplasty for Imperforate Anus with Rectobulbar Urethral Fistula: A Case Report

Abstract

Introduction:

Laparoscopically assisted anorectoplasty (LAARP) was introduced in 2000,¹ and the number of hospitals adopting it for the treatment of high-type anorectal malformation (rectovesical or rectoprostatic fistula) is increasing. However, the application of LAARP for rectobulbar urethral fistula is controversial because precise division of the fistula in the deep pelvic cavity is difficult, and there is a potential risk of posterior urethral diverticulum.^2–4 In this video, we introduce a novel procedure for an imperforate anus with a rectobulbar fistula involving precise ligation of the fistula and appropriate placement of the rectum in the center of the sphincter using combined laparoscopically assisted and anterior sagittal approaches.

Case Report:

A boy weighing 2220 g was born at a gestational age of 37 weeks and diagnosed with an imperforate anus immediately after birth. No associated malformations, including neurological abnormalities and sacral deformities, were noted. Initially, a loop colostomy was placed at the right transverse colon. Distal colostography and urethrography showed a rectobulbar urethral fistula. Anorectoplasty was performed at the age of 4 months (5.8 kg).

Procedure:

Rectal dissection was performed laparoscopically, and the fistula was ligated and resected at a short distance from the urethra. A minimal anterior sagittal incision was made, and a ligature passer was inserted from the center of the external anal sphincter to the center of the puborectalis under laparoscopic vision. The ligature was pulled out from the abdominal cavity, and a pull-through route was formed by cutting the midline of the external sphincter muscle and vertical fibers along the thread using a muscle stimulator. The fistula was identified from the perineum by pulling the thread and resected close to the urethra. The rectum was pulled through and anchored to the muscle fibers. The muscles were closed to surround the rectum and anocutaneous anastomosis was performed. The operative time was 306 minutes.

Results:

The postoperative course was uneventful. The stoma was closed 1 month after the anorectoplasty. MRI performed at 1 year after the anorectoplasty showed the rectum at the center of the sphincter muscle and no residual fistula. Although he is still administered a daily enema, a couple of voluntary bowel movements are seen everyday.

Conclusions:

Combined laparoscopically assisted and anterior sagittal anorectoplasty for an imperforate anus with a rectobulbar urethral fistula was feasible and advantageous for the precise division of the fistula.

All authors have no financial interests or conflicts to disclose

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Runtime of the video: 5 mins 2 secs