A novel laparoscopic technique for anorectal malformation with low recto-bulbar fistulae.

BACKGROUND: The repair of anorectal malformation (ARM) with low recto-bulbar fistula (bowel-to-skin distance: 1-1.5 cm) is contraindicated for laparoscopy due to the difficulty in exposing the fistulae. Posterior or anterior sagittal anorectoplasty is thus conventionally carried out for low recto-bulbar fistula repair. However, these procedures carry the potential risk of wound infection/dehiscence and incontinence. We have developed a single-incision laparoscopic-assisted perineal anorectoplasty (SILPARP) technique. The current study aims to evaluate the safety and efficacy of this novel procedure. METHODS: Fifteen infants with ARMs and low recto-bulbar fistulae who underwent a SILPARP between November 2013 and March 2016 were reviewed. RESULTS: The mean distance between the rectal pouch and the perineal skin was 1.15 cm. The mean age at the time of surgery was 3.92 months. The average operative time was 1.60 h. All patients resumed feeding on postoperative day 1. The median follow-up duration was 7 months. No injury to blood vessels, the urethra or vas deferens was encountered in our series. No mortality, morbidity of wound infection, rectal retraction, anal stenosis, or rectal prolapse was encountered. The postoperative voiding cystourethrogram verified that there was no urethral diverticulum or recurrent fistula. Postoperative pelvic magnetic resonance imaging demonstrated that the distal rectum was located in the center of the pelvic muscle complex. CONCLUSIONS: SILPARP is a feasible alternative treatment for ARM infants with low recto-bulbar fistulae.

Congenital anomaly rectified at birth: one-stage single-incision laparoscopic-assisted anorectoplasty for newborns with anorectal malformations and recto-urethral fistula.

OBJECTIVE: Currently, staged procedures involving stoma formation and closure are the widely accepted treatment for newborns suffering from anorectal malformations (ARM) with recto-urethral fistula. This study aims to evaluate the safety and efficacy of one-stage single-incision laparoscopic-assisted anorectoplasty (SILAARP) as an alternative to the conventional approach. METHODS: Newborns with ARMs and recto-urethral fistula who underwent one-stage SILAARP between June 2013 and December 2014 were reviewed. The procedure involved decompression of the meconium via a small temporary incision of the proximal sigmoid colon followed by a laparoscopic-assisted pull-through. RESULTS: Sixteen ARM newborns [recto-prostatic fistula (6), recto-bulbar fistula (10)] successfully underwent a one-stage SILAARP. The mean age of the neonates at operation was 42.1 h. The average operative time was 2.4 h. The actual pull-through took 1.7 h, which did not differ significantly from 1.9 h in the pull-through procedure of our three-stage SILAARP control group. The median follow-up period was 16 months (8-26 months). No complications were encountered. Postoperative pelvic magnetic resonance imaging verified the centrally placed rectum within the muscle complex. Most patients started having bowel movements on postoperative day 1. Two constipated patients periodically required an enema for 1-3 months. CONCLUSIONS: One-stage SILAARP is safe and effective. It provides complete rectification of ARM with recto-urethral fistula immediately after birth with good cosmesis.

[Quantitative analysis of sensory neurons innervating the muscle levator ani in rats with anorectal malformation].

OBJECTIVE: To quantitatively observe the sensory neurons innervating the levator ani muscle and explore the cause of poor post-operative anorectal function in patients with anorectal malformation (ARM). METHODS: Combining the microsurgery and microinjection techniques, we investigated the deficiency of sensory neurons of the spinal cord in fetal rats with anorectal malformation by injecting the retrograde tracer fluorogold (FG) into the muscle levator ani. Sixty 11 days pregnant female rats were fed with ethylenethiourea (ETU) so as to cause ARM in the fetuses. When the female rats were 20 days pregnant they underwent hysterectomy and the male fetal rats were taken out. Fluorogold (FG), a tracer, was injected into their levator ani muscles. Then the fetal rats were put back into the uteri. Twenty-four hours later hysterectomy was performed for the second time to take out and kill the live fetuses that had undergone FG injection. Their lumbo-sacral spinal cords were taken out, fixed and made into serial longitudinal sections. Digital camera system and fluorescent microscopy were used to observe the FG-labeled sensory neurons. Fifteen normal female rats were used as controls. RESULTS: The FG-labeled sensory neurons innervating levator ani muscle were located mainly in the posterior root ganglia of the 5 th segment of lumber and the 1 st sacral cord. The number of FG-labeled sensory neurons in the normal control fetuses, fetuses without defect of the ETU-fed female rats, fetuses with low type imperforate anus, and fetuses with high type imperforate anus were 11 804 +/- 2362, 10 429 +/- 708, 2886 +/- 705, and 1026 +/- 425 respectively, the latter 2 number being significantly fewer than that in the fetuses without defects (P < 0.05) and that in the normal controls (P < 0.05). CONCLUSION: Defective sensory neurons innervating the levator ani muscle co-exists with the alimentary tract anomaly in rat fetuses with ARM. The defective development of sensory neurons is an important factor likely to contribute to poor post-operative anorectal function despite surgical correction of the ARM.