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Single trocar laparoscopic-assisted colostomy in newborns

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Pediatr Surg Int (2013) 29:651-653

Single trocar laparoscopic-assisted colostomy in newborns

N. T. Liem• T. A. Quynh

Accepted: 11 March 2013 / Published online: 24 March 2013

Abstract To present the technique and outcomes of single trocar laparoscopic-assisted colostomy in newborns. A rectangular skin flap was developed at the left subcostal area and detached from the fascia. Then the fascia and peritoneum were opened longitudinally around 11 mm, and then a 10-mm trocar was inserted into the abdominal cavity. The 10-mm operating laparoscope (Stema, Germany) was inserted through the trocar. The left transverse colon was inspected, grasped and brought outside the abdominal cavity with a Babcock grasper. The skin flap was inserted through a window created at the colon mesentery and secured to the opposite side to elevate the colon. A loop colostomy was performed. From August 2009 to December 2011, single trocar laparoscopic-assisted colostomy was performed for 39 newborns with anorectal malformations, including 26 boys and 13 girls. Mean operative time was 24 ±4 min (range 20–30 min). There were no perioperative deaths or complications. Mean postoperative stay was 3±0.6 days. Single trocar laparoscopic-assisted colostomy is a feasible and safe procedure in newborns.

Keywords: Colostomy. Laparoscopic. Anorectal malformation

Introduction

Colostomy is a common procedure in pediatric surgery, especially for anorectal malformations and Hirschsprung disease. However, its complications are still significantly high [1–10]. Traditionally, colostomy has been performed with a minimal laparotomy. Recently, laparoscopic-assisted colostomy in children with two or four trocars has been introduced [11]. Since 2009 we have been using a single trocar-assisted laparoscopic operation in performing colostomy in newborns.

The aim of this study is to present our technique and its outcomes.

Patients and methods

Patients

All newborn patients with anorectal malformations underwent single trocar laparoscopic-assisted colostomy from August 2009 to December 2011 at the National Hospital of Pediatrics of Vietnam.

Inclusion criteria

• Newborns with high and intermediate types of anorectal malformation.

• Birth weight > 2,000 g.

Exclusion criteria

Severe associated cardiac malformations, birth weight < 2,000 g, rectovestibular fistula.

Surgical technique

The patient was placed in a supine position. A rectangular skin flap was developed at the left subcostal area and detached from the fascia (Fig.1). The abdominal wall was opened longitudinally around 11 mm, and then a 10-mm trocar was inserted into the abdominal cavity. The trocar was connected to CO2 with an insufflation pressure maintained at 10 mmHg. The 10-mm operating laparoscope (Stema, Germany) was inserted through the trocar. The left transverse colon was inspected, grasped (Fig.2), and brought outside the abdominal cavity with a babcock grasper.

The skin flap was inserted through a window created at the colon mesentery and secured to the opposite side to elevate the colon (Fig.3).

Two loops of the colon were approximated together with one suture above the skin flap on two sides. The colon was secured to the abdominal wall with interrupted sutures. The colon was opened transversally, inverted and closed to the skin with interrupted sutures (Fig.4).

Oral feeding was started 12 h after operation. Laparoscopic rectal pull through was performed when the patient was 3 months old and closure of the colostomy was carried out 1 month later.

Results

From August 2009 to Decemcer 2011, single trocar laparoscopic-assisted colostomy was performed for 39 newborns with anorectal malformations, including 26 boys and 13 girls. 28 patients suffered from high type and 11 with intermediate type. Mean operative time was 24±4 min (range 20–30 min). There were no operative or post operative deaths or complications. Mean post operative stay was 3±0.6 days.

Laparoscopic rectal pull through was performed in all patients without any special difficulty. The mean age when laparoscopic rectal pull through was 3.3 ±1.0 months. Colostomy closure was carried out in all 39 patients. The mean age when colostomy was closed was 6.7±1.0 months. There were no complications in waiting for rectal pull-through or closure of colostomy. Urinary infection happened in one patient due to vesicoureteral reflux, which was resolved after ureteral reimplantation.

Discussion

Results from our series revealed that single trocar laparoscopic-assisted colostomy is feasible and safe. The procedure was carried out successfully in all cases. There were no deaths or perioperative complications. The rate of complications in our series was low, whereas it was from 13 to 74.6 % indifferent reports [1–10]. The common complications in other series were mislocation and prolapse [9].

There are some important advantages in our technique. Single trocar laparoscopic-assisted colostomy allows identifying the colon and performing colostomy at an accurate site. There was no mislocation of colostomy in our series. This complication was high in other series [9]. In our technique, the colon was elevated with a skin flap which could prevent colostomy retraction. The colon was divided, inverted and closed with the abdominal wall and the skin, hence abdominal pressure could be reduced immediately after operation and oral feeding can start soon. Early rectal pull through and early closure of the colostomy could be an important factor for the low rate of complications in our series. Chandaramouli [2] also noticed that the incidence of complications increases with time after colostomy and recommended early closure of the colostomy.

There are still controversies concerning the site and type of colostomy. Four common sites are right transverse colon, left transverse colon, descending colon and sigmoid. In our series we created the colostomy at the left transverse colon. The left transverse colon was easily indentified and exteriorized laparoscopically. With creation of the colostomy at the left transverse colon, the distal colon can be

well cleaned with enema before rectal pull-through operation in our series. The laparoscopic rectal pull-through in a second stage was performed without any difficulty relating to the colostomy, whereas the sigmoid colostomy could cause some difficulties for that procedure.

Morgenstern [12] also proposed advantages of the left transverse colostomy including a reduced incidence of prolapse, an increased length of absorptive surface, and absence of adhesions in the right upper quadrant in comparison with the right transverse colostomy.

Three types of colostomy were performed including loop colstomy, divided colostomy, and double barrel colostomy. Advantages of loop colostomy include short operative time and only one abdominal wound. A disadvantage is that it could allow a passage of stool distally, causing urinary tract infection and fecal impaction in the distal pouch of the colon [9]. In our technique, an important length of colon loop was placed outside the abdominal wall. The transverse colon was highly elevated with the skin flap so the passage of stool is limited. We did not see

any inconvenience with this type of loop colostomy. From the results of our study, we can conclude that single trocar laparoscopic-assisted colostomy is feasible, safe and associated with fewer complications.

References

1. Al-Salem AH, Grant C, Khawaja S (1992) Colostomy complications in infants and children. Int Surg 77:164–166

2. Chandramouli B, Srinivasan K, Jagdish S et al (2004) Morbidity and mortality of colostomy and its closure in children. J Pediatr Surg 39:596–599

3. Chirdan LB, Uba FA, Ameh EA et al (2008) Colostomy for high anorectal malformation: an evaluation of morbidity and mortality in a developing country. Pediatr Surg Int 24:407–410

4. Cigdem MK, Onen A, Duran H et al (2006) The mechanical complications of colostomy in infants and children: analysis of 473 cases of a single center. Pediatr Surg Int 22:671–676

5. Figueroa M, Bailez M, Solana J (2007) Colostomy morbidity in children with anorectal malformations (ARM). Cir Pediatr 20:79–82

6. Mollit DL, Malangoni MA, Ballantine TV et al (1980) Colostomy complications in children. An analysis of 146 cases. Arch Surg 115:455–488

7. Nour S, Beck J (1996) Colostomy complications in infants and children. Am R Coll Surg Engl 78:526–530

8. Patwardhan N, Kiely EM, Drake DP et al (2001) Colostomy for anorectal anomalies: high incidence of complications. J Pediatr Surg 36:795–798

9. Pena A, Migotto-Krieger M, Levitt MA (2006) Colostomy in anorectal malformations: a procedure with serious but preventable complications. J Pediatr Surg 41:748–756

10. Sheikh MA, Akhtar J, Ahmed S (2006) Complications/problems of colostomy in infants and children. J Coll Physicians Surg Pak 16:509–513

11. De Carli C, Bettolli M, Jackson CC et al (2008) Laparoscopicassisted colostomy in children. J Laparoendosc Adv Surg Tech A 18:481–483

12. Morgenstern L, Michel SL (1983) The left transverse colostomy. Dis Colon Rectum 26:103–104

 

Combined laparoscopic and modified posterior sagittal approach saving the external sphincter for rectourethral fistula: An easier and more physiologic approach

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Journal of Pediatric Surgery (2013)48, 1450–1453

Combined laparoscopic and modified posterior sagittal approach saving the external sphincter for rectourethral fistula: An easier and more physiologic approach

N.T. Liem, T.A. Quynh

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

Received 5 December 2012; revised 21 February 2013; accepted 2 March 2013

Key words:Imperforate anus; Rectourethral fistula; Laparoscopic; Posterior sagittal approach

Abstract

Aim:To present surgical technique and results of combined laparoscopic and modified posterior sagittal approach (PSAP) saving the external sphincter in the management of rectourethral fistula.

Methods:The operation was started by a laparoscopic approach to dissect around the rectal pouch and separate the rectal pouch from the upper urethra. The PSAP saving the external sphincter was added to completely separate the rectal pouch from the urethra. The fistula was divided and closed. The rectal pouch was then pulled through a tunnel created at the center of the external sphincter and an anoplasty was performed.

Results:From September 2011 to September 2012, 19 patients were operated on using the same technique. Mean age of patients was 4.0 ± 1.8 months. Rectourethral fistula was located in the prostatic urethra in 15 patients and in the bulbar urethra in 4 patients. The mean operative time was 82 ± 13 min. There were no intraoperative complications. Postoperative perforation of the posterior wall of the rectum happened in one patient and required a second laparoscopic operation. Follow-up after closure of colostomy from 1 month to 7 months revealed all patients were able to pass stool spontaneously. All patients could urinate easily. No urethral fistula or diverticulum was detected on voiding cysto-urethrography.

Conclusions:Combined laparoscopic and PSAP saving the external sphincter is the easier and more physiologic approach to manage rectourethral fistula with fewer complications.

Imperforate anus with rectourethral fistula is a common type of anorectal malformations in boys. Since 1982, the (PSAP) has become a standard operation for this anomaly [1]. The laparoscopic approach was introduced by Willital in 1998 and then by Georgeson in 2000 and is being used in many centers[2–17]. However, division and closure of the fistula are still a challenge in the laparoscopic approach for recto-urethral fistula[18–23].

Since September 2011, a combined laparoscopic and PSAP saving the external sphincter has been used in our hospital in the management of rectourethral fistula. The aim of this report was to present the technique and early outcomes of this approach.

1. Patients and methods

1.1. Patients

All patients with rectourethral fistula between September 2011 and September 2012 were operated on by the same technique.

1.2. Surgical technique

1.2.1. Laparoscopic stage

The operation was carried out using 3 trocars: A 5 mm trocar through the umbilicus for the scope, a 5 mm trocar at the left iliac fossa and a 5 mm trocar at the right iliac fossa for instruments. PCO2 pressure was maintained

at 8–10 mmHg. A window was created through the rectal mesentery and a circumferential dissection was carried out around the rectal pouch. A stay suture was placed through the abdominal wall to pull the peritoneal reflection and the bladder forward. The dissection around the rectal pouch was continued 5–10 mm under the peritoneal reflection to the fistula (Fig. 1). The trocars were removed. The wounds were closed and the patient position was changed to the prone jackknife position.

1.2.2. Posterior sagittal approach stage

An inverted Y-shaped incision of the cutaneous and subcutaneous planes was made from the coccyx to the anal dimple. From the superior aspect, the incision was extended around 2 cm higher than the level of the coccyx (Fig. 2). The coccyx was removed. The incision was continued until the external sphincter came into view. The upper midline dissection was continued to the rectal pouch. The upper part of the external sphincter was pulled downward to expose the rectal pouch (Fig. 3). A dissector was passed through the rectourethral septum (Fig. 4), and the rectal pouch was retracted backward with a vessel loop. The dissection around the rectourethral fistula was performed to the urethra. The fistula was divided leaving a stump around 2 mm (Fig. 5).

The mucosa of the fistula was cauterized and then the orifice was closed with interrupted sutures. A neuromuscular stimulator was used to identify the center of the external sphincter, through which a tunnel was created and then dilated gradually with Hegar dilators (sizes 6–12) (Fig. 6). The rectal pouch was pulled through the tunnel, sutured to the external sphincter and then to the skin.

The rectum was sutured to the upper border of the external sphincter by several sutures to prevent rectal retraction, and then the incision was closed.

The new anus was gradually dilated from the 14th postoperative day for a period of one month before closure of colostomy.

2. Results

During the study period, 19 patients were operated on using the same technique. Patient age varied from 3 to 10 months (mean: 4.0 months ± 1.8). Mean patient weight was 6.8 kg ± 1.2 (range: 5–9.5 kg). Associated anomalies included:

- Ventricular septal defect: 2

- Meningocele: 1

- Down syndrome: 1

The fistula was located in the prostatic urethra in 15 patients and in the bulbar urethra in 4 patients.

The mean operative time is presented inTable 1. There were no intraoperative complications. Intraoperative blood loss was not significant. There were no perioperative deaths. Perforation of the posterior wall of the rectum occurred in one patient and required a second laparoscopic operation. Mean postoperative stay was 4 days ± 0.5 (range: 3–5 days). Colostomies were closed 6 weeks after rectal pullthrough.

Follow-up from 1 to 7 months after closure of colostomy (mean: 4.2 months ± 1.8) was obtained in all patients. All patients were able to pass stool spontaneously and urinate easily. No urethral fistula or diverticulum was detected on voiding cysto-urethrography. Rectal mucosal excess was present in 5 patients and required a second operation to remove. All patients are still too young to assess fecal continence.

3. Discussion

Our results reveal that the combined laparoscopic and modified posterior sagittal approach saving the external sphincter is feasible and safe. All operations were completed by this combined approach. There were no perioperative deaths or complications. Our approach has some advantages in comparison with the standard laparoscopic approach [2] with regard to separating the rectal pouch from the urethra and the management of the fistula.

Separation of the rectal pouch from the urethra is a difficult step in the laparoscopic operation for rectourethral fistula, especially rectobulbar fistula. Damage to the urethra or vas is a potential risk. In our operation, the upper part of the rectal pouch was easily separated from the urethra via the laparoscopic approach. In all patients, the separation between these two structures was noticed at the start of modified PSAP. The complete separation of these two structures was easily realized by pulling the rectal pouch backward while pulling the external sphincter downward. In a laparoscopic approach, it is usually difficult to divide and close the fistula close to the urethra. The sutures are difficult to carry out in a deep and small pelvis. Some surgeons left a long rectal stump whereas other surgeons just left the fistula open and kept a bladder catheter for a long period of time after operation [18–20]. This way of management can cause postoperative urethral fistula or diverticulum[8,11,18–23].

In our approach, we can observe the fistula directly, divide and close it easily. The urethral fistula or diverticulum has not been encountered in our series. The external sphincter was exposed and protected maximally. Its center could be identified using a muscle stimulator and the rectal pouch pulled through a tunnel created at the center of the sphincter. The integrity of the sphincter is an important factor affecting fecal incontinence and constipation. No patient in this series suffered from postoperative constipation. However all patients are still too young to assess the fecal continence. One disadvantage of our technique is the change of patient position. However, the operative time in our series was shorter than in other series where the operation was performed by a single laparoscopic approach[11,16,18].

From our results, we can conclude that combined laparoscopic and modified PSAP saving the external sphincter is a good alternative approach in the management of rectourethral fistula.

References

[1] Pena A. Posterior sagittal anorectoplasty: important technical considerations and new applications. J Pediatr Surg 1982;17:796-811.

[2] Willital GH. Endosurgical intrapuborectal reconstruction of high anorectal anomalies. Pediatr Endosurg Innov Tech 1998;2:5-11.

[3] Georgeson KE, Inge TH, Albanese CT. Laparoscopically assisted anorectal pull-through for high imperforate anus—a new technique. J Pediatr Surg 2000;35:927-30.

[4] Kudou S, Iwanaka T, Kawashima H, et al. Midterm follow-up study of high-type imperforate anus after laparoscopically assisted anorectoplasty. J Pediatr Surg 2005;40:1923-6.

[5] Lima M, Tursini S, Ruggeri G, et al. Laparoscopically assisted anorectal pull-through for high imperforate anus: three years' experience. J Laparoendosc Adv Surg Tech A 2006;16:63-6.

[6] Vick LR, Gosche JR, Boulanger SC, et al. Primary laparoscopic repair of high imperforate anus in neonatal males. J Pediatr Surg 2007;42:1877-81.

[7] Srimurthy KR, Ramesh S, Shankar G, et al. Technical modifications of laparoscopically assisted anorectal pull-through for anorectal malformations. J Laparoendosc Adv Surg Tech A 2008;18:340-3.

[8] El-Debeiky MS, Safan HA, Shafei IA, et al. Long-term functional evaluation of fecal continence after laparoscopic-assisted pull-through for high anorectal malformations. J Laparoendosc Adv Surg Tech A 2009;19(Suppl 1):S51-4.

[9] Kimura O, Iwai N, Nasaki Y, et al. Laparoscopic versus open abdominoperineal rectoplasty for infants with high-type anorectal malformation. J Pediatr Surg 2010;45:2390-3.

[10] Koga H, Miyano G, Takahashi T, et al. Comparison of anorectal angle and continence after Georgeson and Peña procedures for high/-intermediate imperforate anus. J Pediatr Surg 2010;45:2394-7.

[11] Hay SA. Transperineal rectovesical fistula ligation in laparoscopicassisted abdominoperineal pull-through for high anorectal malformations. J Laparoendosc Adv Surg Tech A 2009;19(Suppl 1):S77-9.

[12] Baillez MM, Cuenca ES, Mauri V, et al. Outcomes of males with high anoretal malformations treated with laparoscopic-assisted anorectal pull-through: preliminary results of a comparative study with the open approach in a single institution. J Pediatr Surg 2011;46:473-7.

[13] Bischoff A, Levitt MA, Pena A. Laparoscopy and its use in the repair of anorectal malformations. J Pediatr Surg 2011;46:1609-17.

[14] De Vos C, Arnold M, Sidler D, et al. A comparison of laparoscopicassisted (LAARP) and posterior sagittal (PSARP) anorectal malformations. S Af J Surg 2011;49:39-43.

[15] England RJ, Warren SL, Bezuidenhout L, et al. Laparoscopic repair of anorectal malformations at the Red Cross War Memorial Children’s Hospital: taking stock. J Pediatr Surg 2012;47:565-70.

[16] Tong QS, Tang ST, Pu JR, et al. Laparoscopically assisted anorectal pull-through for high imperforate anus in infants: intermediate results. J Pediatr Surg 2011;46:1576-8.

[17] Wong KK, Wu X, Chan IH, et al. Evaluation of defecative function 5 years or longer after laparoscopic-assisted pull-through for imperforate anus. J Pediatr Surg 2011;46:2313-5.

[18] Podevin G, Petit T, Mure PY, et al. Minimally invasive surgery for anorectal malformation in boys: a multicenter study. J Laparoendosc Adv Surg Tech A 2009;19(Suppl 1):S233-5.

[19] Rollins MD, Downey EC, Meyers RL, et al. Division of the fistula in laparoscopic-assisted repair of anorectal malformations—are clips or ties necessary? J Pediatr Surg 2009;44:298-301.

[20] Lopez PJ, Guelfand M, Angle L, et al. Urethral diverticulum after laparoscopically-assisted anorectal pull-through (LAARP) for anorectal malformation: is resection of the diverticulum always necessary? Arch Esp Urol 2010;63:297-301.

[21] Koga H, Okazaki T, Yamataka A, et al. Posterior urethral diverticulum after laparoscopic-assisted repair of high-type anorectal malformation in a male patient: surgical treatment and prevention. Pediatr Surg Int 2005;21:58-60.

[22] Koga H, Kato Y, Shimotakahara A, et al. Intraoperative measurement of rectourethral fistula: prevention of incomplete excision in male patients with high-/intermediate-type imperforate anus. J Pediatr Surg 2010;45:397-400.

[23] Uchida H, Iwanaka T, Kitano Y, et al. Residual fistula after laparoscopically assisted anorectoplasty: is it a rare problem? J Pediatr Surg 2009;44:278-81.

Lần cập nhật cuối ( Thứ ba, 30 Tháng 12 2014 15:16 )
 

KẾT QUẢ BƯỚC ĐẦU ĐIỀU TRỊ DỊ TẬT HẬU MÔN TRỰC TRÀNG LOẠI CAO VÀ TRUNG GIAN BẰNG PHẪU THUẬT NỘI SOI

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 Abstract

Aim: Described surgical technique and early outcomes of laparoscopic assisted anorectal pull through for anorectal malformations.

MATERIALS AND METHODS: All patients with anorectal malformations underwentlaparoscopic surgery by the same surgeonfrom January 2009 to August 2013 including 115 boys and 35 girls. The age of patients varied from 2-30 months (mean 3.9 ± 2.59 months). The operation was carried out using three trocars. CO2 pressure was maintained from 8-10 mmHg. Single laparoscopic approach was used for rectovesical fistula. Combined laparoscopic and modified PSAP were performed for rectourethral fistula of anal atresia without fistula.

RESULTS:Single laparoscopic assisted rectal pull-through was performed in 78 patients, combined laparoscopic and modifiied PSARP preservingthe sphincter intact were used in 72 patients. Of these 150 patients, 39 were found to have bladder fistula, 42 had a rectoprostate fistula, 14 rectobulbar fistula, 27 had a rectovaginal fistula, and 28 without fistula.  Operative time ranged from 45 - 120 minutes (mean 71.2 ± 15.9 minutes). One patient had vaginal perforation during operation.  One patient had rectal necrosis postoperative 14 days and reoperation by laparoscopic successful.

The mean hospital stay was 4.3 ± 2.2 days (range, 3 – 30 days). Follow-up from 7 to 60 months (mean 24.2 ± 14.5 months) was obtained in 119 patients. Number of stool varied from 1 to 7 times/day, 45 patients had sometime incontinence, 5 patients had constipation with 1 time/2 to 3 days. 27 patients had rectal mucosal prolapse required a second operation. No urethral diverticulum or urethral fistula have seen on voiding cystography in male patients after operation

CONCLUSION: Laparoscopic assisted rectal pull-through is feasible, safe and effective foranorectal malformations.

I. Đặt vấn đề

Phẫu thuật nội soi được Willital giới thiệu lần đầu tiên năm 1998 và được Georgeson tiếp tục phát triển năm 2000 (1,2). Đến nay phương pháp phẫu thuật nội soi đã được ứng dụng tại nhiều trung tâm trên thế giới (3-4). Mặc dù vậy chưa có báo cáo nào với số bệnh nhân đủ lớn và thời gian theo dõi lâu dài để đánh giá đầy đủ những ưu và nhược điểm của phương pháp này.

Mục đích của nghiên cứu này là nhằm đánh giá kết quả sớm của phẫu thuật nội soi điều trị thể loại cao và trung gian với 150 trường hợp.

II. Tư liệu và phương pháp nghiên cứu

II.1. Bệnh nhân

Bao gồm các bệnh nhận bị dị tật hậu môn trực tràng : rò trực tràng bàng quang, rò trực tràng niệu đạo, còn ổ nhớp, teo hậu môn khong có rò.

Tiêu chuẩn loại trừ: các bệnh nhân đã mổ trước đó bằng một kĩ thuật khác.

II.2. Phương pháp nghiên cứu

Là phương pháp nghiên cứu thử nghiệm lâm sàng không có nhóm chứng

Các biến số nghiên cứu chính: thể loại dị tật, thời gian mổ, biến chứng sớm sau mổ, kết quả sớm sau khi ra viện

Kết quả về chức năng đại tiện: sử dụng tiêu chuẩn Krickenbec cho trẻ ≥ 3 tuổi (5).

Kĩ thuật mổ: Trẻ nằm theo chiều ngang bàn mổ. Phẫu thuật được tiến hành qua 3 troca: 1 qua rốn cho ống soi, 1 ở chậu phải và 1 ở hố chậu trái. Áp lực bơm hơi từ 8-10mmHg, lưu lượng từ 2-3 L/p.

Tạo cửa sổ qua mạc treo trực tràng. Bóc tách quanh trực tràng về phía tiểu khung đến sát nếp gấp phúc mạc trực tràng âm đạo hoặc trực tràng bàng quang. Khâu treo nếp phúc mạc vào thành bụng để giúp bóc tách mặt trước bóng trực tràng dễ dàng.

Nếu vị trí rò ở cao ( trực tràng-bàng quang) , tiến hành cắt và khâu lỗ rò.

Tiếp tục bóc tách tìm cơ nâng hậu môn.

Dùng kích thích cơ tìm vị trí trung tâm của cơ thắt ngoài từ tầng sinh môn. Rạch da hình chữ thập qua vết tích hậu môn. Bóc tách các vạt da bộc lộ cơ thắt ngoài.

Tạo đường hầm qua trung tâm cơ thắt ngoài từ tầng sinh môn vào tiểu khung đi giữa 2 cơ nâng hậu môn,

Nong dần đường hầm đến que nong số 12.

Đặt troca số 10 qua đường hầm vào tiểu khung. Kéo bóng trực tràng xuống tầng sinh môn. Tạo hình hậu môn.

Nếu đường rò thấp hơn ( trực tràng-niệu đạo, trực tràng ổ nhớp) hoặc teo hậu môn không rò,sau khi bóc tách bóng trực tràng dưới nếp phúc mạc khỏi 1cm ở mặt trước và sát đến cơ nâng hậu môn ở phía sau thì dừng thì nội soi. Rút và khâu các lỗ troca.

Chuyển bệnh nhân sang tư thế nằm sấp theo hình dao díp gập. Rạch da từ đỉnh xương cụt đến vết tích hậu môn rồi kéo sang hai bên giống hình chữ Y lộn ngược.. Bóc tách các vạt da bộc lộ cơ thắt ngoài.Bóc tách phía trên đường rạch đến cơ mu trực tràng. Cắt dây chằng giữa xương cụt và trực tràng, kéo cơ mu trực tràng xuống dưới bộc lộ bóng trực tràng. Luồn dây giữa trực tràng niệu đạo hoặc âm đạo ( con gái) kéo bóng trực tràng ra phía sau.

Tách bóng trực tràng đến phần tận cùng. Cắt rời bóng trực tràng cách phần tận cùng khoảng 5mm-10mm. Kiểm tra nếu có đường rò, cắt phần tận cùng của trực tràng đến sát niệu đạo. Khâu lỗ rò. Nếu không có đường rò, cắt bỏ hết phần tận cùng của trực tràng.

Tạo đường hầm qua trung tâm cơ thắt ngoài vào tiểu khung. Kéo bóng trực tràng qua đường hầm. Tạo hình hậu môn.

Nong hậu môn sau mổ từ ngày thứ 15 hàng ngày. Có thể đóng hậu môn nhân tạo sau 1 tháng,.

III. Kết quả nghiên cứu.

Trong thời gian nghiên cứu đã có 150 bện nhân được phẫu thuật bao gồm 115 là con trai và 35 là con gái. Tuổi thấp nhất là 2 tháng và cao nhất là 30 tháng, cân nặng thấp nhất là 9,5kg, trung bình là 6,3±3,5kg.

Các thể loại dị tật được trình bày trong bảng 1:

Bảng 1: Các loại dị tật

     Thể loại                                   Số lượng

TỈ lệ %

Teo hậu môn không rò

28

18.7

Rò trực tràng bàng quang

39

26.0

Rò trực tràng niệu đạo tiền liệt tuyến

42

28.0

Rò trực tràng niệu đạo hành

14

9.3

Còn ổ nhớp

27

18.0

Total

150

100.0

 Dị tật kèm theo:

15 bệnh nhân bị Down

3 bệnh nhân chỉ có 1 thận

1 bệnh nhân bị cứng khớp háng bẩm sinh.

1 bệnh nhân bị hẹp động mạch phổi

3 bệnh nhân bị thoát vị màng não tuỷ cùng cụt

10 bệnh nhân có luồng trào ngược bàng quang niệu quản

14 bệnh nhân có dị tật tim mạch

4 bệnh nhân bị teo thực quản

Nội soi đơn thuần được tiến hành ở  81 bệnh nhân trong khi đó nội soi kết hợp với đường sau trực tràng  được tiến hành ở 69 bệnh nhân.

69  trường hợp kết hợp sau trực tràng do:

-  66 trường hợp túi cùng trực tràng xuống thấp.

-   3 trường hợp có thoát vị màng não tủy kết hợp.

Thời gian mổ: Ngắn nhất: 45phút, dài nhất 120 phút, Mean 71.2  ± 15.9 phút

 Biến chứng trong mổ:

Có 1 bệnh nhân thủng âm đạo khâu lại kết quả tốt

Biến chứng sau mổ:

2 bệnh nhân bị nhiễm trùng miệng nối, niêm mạc tụt lên không phải khâu 

1 bệnh nhân bị hoại tử mặt sau trực tràng ngày thứ 14. Mổ lại hạ đại tràng để mỏm thừa diễn biến tốt

Ngày điều trị sau mổ:Ngắn nhất 3 ngày, dài nhất 30 ngày,trung bình 4.3  ± 2,2 ngày.

Bệnh nhân nằm viện lâu nhất do có kết hợp tim bẩm sinh ( hẹp động mạch phổi)

                Theo dõi sau đóng hậu môn nhân tạo.                    

Theo dõi được 119 bệnh nhân (79,3%) . Thời gian theo dõi: ngắn nhất 7 tháng, dài nhất 60 tháng, trung bình 24.2 ± 14.2 tháng. Có 4 bệnh nhân bị hẹp vòng dau quanh hậu môn, 28 bệnh nhân bị thừa niêm mạc hậu môn.

Số lần đại tiện được trình bày trong bảng 2:

                Bảng 2 : Số lần đại tiện sau mổ.

   Số lần đại tiện

Số lượng

Ti le%

 

1 - 2 lần

52

34.7

 

3 - 4 lần

47

31.3

 

5 - 6 lần

15

10.0

 

> 6 lần

1

.7

 

táo bón

4

2.7

 

Total

119

79.3

Có 24 bệnh nhân đã ≥ 3 tuổi, chức năng dại tiện được đánh giá theo tiêu chuẩn Krickenbeck:

Bảng 3: Chức năng đại tiện theo Krickenbeck.

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