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Laparoscopic rectal pull-through for persistent cloaca: an easier approach for a complex anomaly

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Laparoscopic rectal pull-through  for persistent cloaca:

an easier  approach for a complex anomaly

Nguyen Thanh Liem *, Tran Anh Quynh

Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam

Received 24 October 2011; revised 11 January 2012; accepted 3 February 2012

Key words:

Laparoscopic;

Rectal pull-through; Persistent cloaca

Abstract

Aim: The aim of this study was to describe the surgical technique and initial outcomes of

laparoscopic- assisted anorectal pull-through for persistent cloaca.

 

Materials and Methods: From January 2008 to June 2010, laparoscopic-assisted rectal pull-through

was performed for 10 patients with persistent cloaca. The patient ages ranged from 3 to 9 months. The

operation was carried out using 4 trocars. CO2  pressure was maintained between 8 and 12 mm Hg.

Results: Laparoscopic-assisted rectal pull-through was successfully performed in all patients.

Operative time ranged from 80 to 120 minutes (mean, 91.5 ± 10 minutes). There were no

intraoperative or postoperative deaths or complications. The mean hospital stay was 4.4 ± 0.5 days

(range, 4-5 days). The length of follow-up varied from 6 to 24 months (mean, 12.9 ± 5.7 months) in

all 10 patients. Anal stenosis was not observed in any patient. Seven patients had 1 to 2 stools

per day, 2 patients had 3 stools per day, and 1 patient had 1 stool every 2 days. No patient had

fecal incontinence.

Conclusion: Laparoscopic rectal pull-through is a feasible, effective, and less traumatic approach

for anorectoplasty in patients with persistent cloaca.

 

 

Persistent cloaca is the most severe anomaly among anorectal malformations. The treatment of this

defect is still a great surgical challenge. Abdominal and posterior sagittal approaches have been

used for the management of this defect [1-4]. However, rectoplasty, urethroplasty, and vaginoplasty

in the same stage are extremely dif?cult procedures that can only be done by very skilled surgical

teams [4].

Since 2008, we have carried out laparoscopic rectal pull- through to perform anorectoplasty for

cloacal malformations.

The aim of this article was to present our technique and early outcomes of laparoscopic rectal

pull-through in the management of cloacal anomalies.

1. Patients  and method

From January 2008 to June 2010, the technique was performed in 10 patients with persistent cloaca.

Colostomy was carried out in the newborn period in all patients at the left colon. Laparoscopic

rectal pull-through was performed as a second-stage procedure. The rectal pouch ended above the

pubococcygeal line in 7 patients and under the pubococcygeal line in 3 patients. The length of the

cloaca was measured in 4 patients: 3 cm in 1 patient, 2 cm in

2 patients, and 1.5 cm in 1 patient.

The patient was positioned transversely at the end of the operating table. The bladder was emptied

by a urinary catheter. The surgeon and the surgical assistant stood at the patient's head. The

operation was performed using 3 trocars: a 5-mm trocar in the midline 2 cm above the umbilicus for

the scope, a 5-mm trocar in the right iliac fossa, and a 5-mm trocar in the left iliac fossa. An

additional 3-mm trocar was used when necessary.

CO2 pressure was maintained between 8 and 12 mm Hg. Rectal  dissection  was  started  by  creating 

a  window through the rectal mesentery then continuing circumferen- tially around the rectum down

to the fistula between the rectum and urogenital sinus. The dissection was kept as close  as 

possible  to  the  rectal  wall.  The  fistula  was exposed. The first  suture was placed in one half

of the fistula and then the fistula was divided (Fig. 1). A second suture  was  used  to  close  the 

fistula  stump  completely. Dissection and inspection were carried out to identify the

levator muscles.

 

laparoscopic_rectal_pull-through_for_persiste - Upanh.com

Fig. 1     The fistula being divided after placing the first suture.

The peritoneum was exposed by ?exing the patient's knees. The center of external sphincter

contraction was identi?ed using a cutaneous electrical stimulator on the perineum. A cruciate skin

incision was made through this point. The skin and subcutaneous tissue were dissected to expose the

external sphincter as much as possible, and the electrical stimulator on the external sphincter was

again used to identify the center (Fig. 2).

 

laparoscopic_rectal_pull-through_for_persiste - Upanh.com

Fig. 2     The external sphincter exposed and stimulated with a muscle stimulator.

A small mosquito forceps was introduced through this

point into the pelvis between the 2 elevator muscles. The forceps was withdrawn and replaced by a small dilator. The created tunnel was dilated progressively until a size-12 dilator could be passed easily (Fig. 3).

 

laparoscopic_rectal_pull-through_for_persiste - Upanh.com

Fig. 3     A tunnel through the center of the external sphincter and between the levators being

progressively dilated.

A 12-mm trocar was inserted through the tunnel into the pelvis. The rectum was grasped by a grasper and pulled

through the tunnel while removing the trocar.

Anoplasty was performed by suturing the rectum to the external sphincter and then to the skin. Oral

intake was resumed on the second postoperative day in all patients.

Anal dilation was started 2 weeks after the operation and

continued until colostomy closure.

The colostomy was closed 2 months after the rectal laparoscopic pull-through.

Vaginoplasty and urethroplasty were performed in a delayed and separate stage through the perineal

approach in 2 patients when they were 26 and 29 months, respectively.

In  patient  1,  the  length  of  the  common  urogenital channel was 1.5 cm. The skin incision was

made in a letter “W” shape. The posterior and lateral walls of the channel were dissected and

mobilized, and then, the posterior wall of the common channel was opened longitudinally to the

urethral and vaginal openings. The lateral walls of the channel were divided to the urethral

opening. The urethra was separated from the vagina. The posterior wall of the urethra and the

anterior wall of the vagina were constructed (Fig. 4). The posterior wall of the vagina was

constructed with a triangle skin ?ap, and the lateral wall of the vagina was sutured to the skin

(Fig. 5). The postoperative course was uneventful. There was no urethral fistula, and the patient

achieved urinary continence immediately after removing the bladder catheter.

In  patient  2,  the  length  of  the  common  urogenital channel  was  3  cm.  Total  urogenital 

mobilization  was carried out (Fig. 6), and then, vaginoplasty and urethro- plasty were performed according to the

Peña technique [4]. There were no perioperative complications. The patient can void normally.

laparoscopic_rectal_pull-through_for_persiste - Upanh.com

Fig. 4     The posterior wall of the urethra and the anterior wall of the vagina being constructed.

 

laparoscopic_rectal_pull-through_for_persiste - Upanh.com

Fig. 5     The urethra and vagina after construction.

 

laparoscopic_rectal_pull-through_for_persiste - Upanh.com

Fig. 6     The common urogenital channel.

 

2. Results

Patient ages varied from 3 to 9 months (mean, 4.3 ± 2.5 months). Mean operative time was 91.5 ± 10

minutes (range, 80-120 minutes). Intraoperative blood loss was insigni?cant. Conversion to open

surgery was not required in any patient. There were no operative or postoperative

 

complications.  Mean  postoperative  stay  was  4.4  ±  0.5 days. The length of follow-up varied

from 6 to 24 months (mean, 12.9 ± 5.7 months) in all 10 patients. Anal stenosis was not observed in

any patient. Seven patients had 1 to 2 stools  per  day,  2  patients  had  3  stools  per  day, 

and

1 patient had 1 stool every 2 days. No patient had fecal incontinence. The main patient

characteristics are presented in Table 1.

3. Discussion

Our technique is similar to the Georgeson technique for imperforate anus [5]. However, there are

some differences between our techniques:

We   placed  trocars  as   described  above  instead  of placing all trocars in the umbilicus and

in the right abdominal side as in the Georgeson technique. With this placement, the operation is

easily carried out, especially when dissecting the lower pelvis and creating a tunnel through the

elevator muscles.

We performed a cruciate perineal skin incision and exposed the external sphincter nearly

completely. By using a muscle stimulator, the center of the external sphincter and the midline

between the 2 elevator muscles can be identi?ed by observing from the perineum and from

laparoscopy. In this way, the tunnel through the center of the external sphincter and between the 2

elevator muscles could be positioned precisely. This ensures postoperative fecal continence.

Our results revealed that laparoscopic rectal pull-through is feasible for anorectoplasty in

patients with persistent cloaca. There were no open conversions in our series. This approach is

safe. There were no operative or postoperative complications. The operative time is acceptable.

Postopera- tive recovery was prompt and postoperative stay was short. Fecal continence was achieved

in all patients.

 

bang - Upanh.com

From the results of our series, we can conclude that laparoscopic rectal pull-through is a

feasible, effective, and less traumatic approach for anorectoplasty in patients with persistent

cloaca.

Acknowledgment

The authors thank John Taylor, MD, PhD, clinical associate professor, Department of Pediatrics,

School of Medicine, University of Washington, for his careful reading and valuable comments on the

manuscript.

References

[1] Hendren  WH.  Cloacal  malformations: experience  with  105  cases.

J  Pediatr  Surg  1992;27:890-901.

[2] Leclair MD, Gundetti M, Kiely EM, et al. The surgical outcomes of total urogenital mobilization

for cloacal repair. J Urol 2007;177:1492-5.

[3] Peña A. The surgical management of persistent cloaca: results in 54 patients  treated with  a 

posterior sagittal approach. J  Pediatr  Surg

1989;24:590-8.

[4] Levitt MA, Peña A. Cloacal malformations: lessons learned from 490 cases. Semin Pediatr Surg

2010;19:128-38.

[5] Georgeson K, Inge TH, Albanese CT. Laparoscopically assisted anorectal pull-through for high

imperforate anus — a new technique. J Pediatr Surg 2000;35:927-30.

 

 

 

 

 


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DANH SÁCH BAN CHẤP HÀNH NHIỆM KỲ II HỘI PHẪU THUẬT NHI VIỆT NAM (2012 – 2017)

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