腹腔镜高位肛门闭锁一期成形术4例报告

目的 探讨腹腔镜辅助下高位肛门闭锁一期肛门成形术的可行性。方法先天性高位肛门闭锁患儿4例，男3例，年龄1天～3天；女1例，年龄3个月，为先天性-穴肛畸形。术中首先腹腔镜监视下，游离直肠，分离结扎断离直肠尿道瘘管；然后通过穿刺盆底肌肉中心形成隧道，将直肠从中脱出，与会阴皮肤吻合。结果4例均在腹腔镜辅助下一期完成肛门成形术，腹腔镜手术操作时间40分钟～90分钟，平均718分钟。出血量(5—20)ml，平均8．3ml。无需要输血，未出现术中并发症。所有病人术后恢复顺利，于术后11天去除尿管和膀胱造瘘管，无尿道瘘憩室发生，无切口感染。术后随访3月至1年，I例手术后1月出现肛门狭窄，于术后3月行狭窄段切除术治愈。另外3例无并发症发生，目前4例排便控制功能良好。结论腹腔镜铺助肛门一期成形术是治疗高位肛门闭锁的有效方法，手术打击小，处理直肠泌尿系瘘方便，辨认盆底肌中心准确，可免除患儿分期手术。     

腹腔镜技术在小儿肛门闭锁中的应用

目的探讨腹腔镜辅助下先天性高位、中位肛门闭锁患儿手术的可行性。方法 6例先天性高位、中位肛门闭锁患儿,均在腹腔镜监视下游离出直肠盲端及瘘管,切断瘘管,腹腔镜下修补尿瘘或阴道瘘。电刺激找到盆底肌肉中心点,做成一隧道,将直肠盲端从此隧道内拖出,与肛穴缘皮肤吻合。结果 6例均在腹腔镜辅助下完成直肠肛门成形术。腹腔镜手术操作时间35～74 min（平均46.5 min）,术中出血量〈15 ml,住院时间10～18 d（平均14.5 d）。无并发症发生。术后随访6～12个月,无肛门失禁、直肠后间隙感染等并发症,均能够正常排便。肛门功能评分优4例,良2例。结论腹腔镜辅助下直肠肛门成形术是一种安全、有效的方法,处理瘘管方便,辨认盆底肌中心准确,手术后可获得良好的排便功能,具有创伤小、恢复快、疗效优等特点。     

经会阴离断直肠末端一期手术治疗先天性肛门闭锁并肛前瘘

目的总结经会阴离断直肠末端一期手术治疗先天性肛门闭锁并肛前瘘的初步经验。方法回顾性分析19例临床资料,其中肛门闭锁合并直肠前庭瘘9例、直肠阴道瘘2例、直肠会阴瘘7例和直肠尿道瘘1例。均经会阴离断直肠末端一期行经会阴肛门成形和肛前瘘修补手术。结果所有患者手术顺利,术后恢复良好,平均随访3年(1个月~6年),瘘管未复发,肛门排便和控便功能满意。结论经会阴离断直肠末端一期肛门成形和肛前瘘修补治疗先天性肛门闭锁并肛前瘘创伤小,疗效满意。     

肛门闭锁直肠尿道瘘的治疗

目的:探讨肛门闭锁并有直肠尿道瘘病儿的合理治疗方案以提高治愈率。方法:总结分析1984～1994年收治的先天性闭肛合并直肠尿道瘘新生儿40例,闭肛术后残留直肠尿道瘘12例共52例的手术治疗方法及效果。结果:41例新生儿期先行结肠造瘘,二期骶会阴肛门成形术同时行尿瘘修补术者,39例治愈;11例新生儿期肛门成形术后残留直肠尿道瘘者,经尿道瘘修补术,8例治愈。结论:先天性肛门闭锁合并直肠尿道患儿,宜先施行结肠造瘘,Ⅱ期再经骶会阴肛门成形,尿瘘修补术。对肛门成形术后残留尿道瘘者,经会阴人路尿瘘修补术为最常用术式,术前先行结肠造瘘以预防切口感染致手术失败,经直肠腔内粘膜覆盖修补尿瘘有操作简单,且无需先行结肠造瘘的优点。     

腹腔镜辅助高位肛门闭锁手术的初步经验

目的探讨腹腔镜技术在治疗小儿高位肛门闭锁中的应用价值。方法本组高位肛门闭锁患儿共6例,其中2例合并直肠尿道瘘,1例合并一穴肛畸形。术中在腹腔镜下游离直肠,结扎离断直肠尿道瘘(阴道瘘)。找到耻骨直肠肌收缩中心并加以扩张,将直肠盲端自此隧道中拖出与会阴部皮肤缝合。3例并发球形结肠患儿,在腹外切除病变结肠,将近端结肠自耻骨直肠肌中心拖出行括约肌成形术。结果本组6例的手术均顺利完成,腹腔镜操作时间70～110 min(平均82 min),出血量10～20ml(平均14.5ml)。1例行臀大肌瓣转移外括约肌成形术,术后发生感染,改行横结肠单口造瘘术。本组无尿道瘘(阴道瘘)、憩室及切口感染的发生。术后随访6例3个月～3年,肛门无狭窄,大便控制良好。结论腹腔镜辅助便于处理直肠尿道瘘(阴道瘘),可准确辨认耻骨直肠肌收缩中心,减少了术后大便失禁的发生。     

Hem-o-10k在腹腔镜肛门成形术中的应用

目的探讨Hem-o—lok在腹腔镜肛门成形术处理直肠尿道瘘中的价值。方法2012年1月～2013年12月采用腹腔镜治疗15例中高位肛门闭锁,在距球部、膜部或膀胱颈部尿道0．5cm处应用Hem—o—lok夹闭瘘管处理直肠尿道瘘。结果均在腹腔镜辅助下完成肛门成形＋尿道瘘修补术,腹腔镜手术（包括会阴手术）操作时间90～150min（平均120rain）。出血量10～20ml（平均15m1）,无需要输血者,无术中并发症发生。术后7d拔除尿管,无排尿困难。15例随访2～12个月（平均5个月）,术后排尿功能基本正常,无尿道瘘复发,无尿道狭窄发生,肛门外观正常,2例患儿轻度直肠黏膜脱垂。结论腹腔镜辅助下Hem-o-lok夹闭处理直肠尿道瘘,更加精准、方便,降低手术难度,可取得满意的治疗效果。     

肛门闭锁术后残留直肠尿道瘘的治疗

目的 :探讨肛门闭锁术后残留直肠尿道瘘的手术方式及疗效。方法 :8例本病患儿 ,根据病变情况分别采用直肠内直肠尿道瘘修补及经腹会阴联合术式行乙状结肠部分切除、直肠粘膜剥离、瘘管结扎、结肠经直肠肌鞘内拖出肛门成形术治疗。结果 :术后全部治愈出院 ,随访 1～ 6年无复发 ,疗效满意。结论 :上述两种术式较其他术式具有修补牢靠、术式简单、不易复发等优点 ,是目前修补直肠尿道瘘较理想术式之一。     

腹腔镜在婴幼儿肛门闭锁手术中的应用

比较小儿科其他病种的腹腔镜临床应用，在先天性肛门直肠畸形中的应用相对开展较晚，并且其推广和普及程度也不同于其他术式，相对滞后，并存在一定争议。美国Georgeson等2000年首先报道了11例腹腔镜辅助下将直肠经会阴拖出治疗先天性肛门闭锁，其中7例为新生儿期先行结肠造瘘术后，二期在腹腔镜辅助下行肛门直肠拖出成形术；4例为新生儿一期拖出，     

1例直肠舟状窝瘘患者的手术护理

我院于2004年3月采用会阴经直肠内瘘管修补肛门成形术治疗1例先天性肛门闭锁并直肠舟状窝瘘。该手术具有操作简单，不损伤会阴复合体，尽可能地保留外括约肌功能生理状态的优点，治疗效果满意。护理体会如下。     

远端乙状结肠造瘘术后腹腔镜辅助二期肛门成形术治疗先天性肛门闭锁的疗效评价

目的探讨远端结肠造瘘术后腹腔镜辅助二期肛门成形术治疗先天性肛门闭锁的术后疗效。方法将我院2008年10月~2014年10月10例新生儿期在外院行远端结肠造瘘术的中高位肛门闭锁患儿,二期在我院行腹腔镜辅助肛门成形术设为A组,10例合并直肠尿道瘘,2例合并双侧输尿管膀胱返流,术中游离远端结肠,合并尿道瘘者于瘘管颈部缝扎后离断直肠尿道瘘管,远端结肠下托至肛门口有张力,将远端结肠切除行近端结肠拖出成形肛门。选择2008年6月~2014年6月20例中高位肛门闭锁行经典三期手术(造瘘-腹腔镜辅助下直肠拖出肛门成形术-关瘘)设为B组作为对照,比较2组术后肛肠测压指标,术后1年肛周肌群厚度和Kelly评分。结果 A组随访12~60个月,(35±6)个月;B组随访15~60个月,(46±4)个月。2组肛门直肠组织的形态无明显差异。A、B组肛管静息压分别为(25.85±3.68)、(26.93±4.54)mm Hg,无统计学差异(t=-0.651,P=0.520);A组最大收缩压(35.90±8.44)、B组(41.14±9.60)mm Hg,无统计学差异(t=-1.464,P=0.154);2组肛管持续收缩长度分别为(12.53±0.75)、(12.67±0.78)mm,无统计学差异(t=-0.469,P=0.643);2组直肠内超声观察肛门外括约肌、耻骨直肠肌的厚度分别为(1.93±0.36)、(2.12±0.43)mm,无统计学差异(t=-1.200,P=0.240);2组肛门排便功能的Kelly评分比较无显著统计学差异(Z=-0.334,P=0.738)。结论远端结肠造瘘术后腹腔镜辅助二期肛门成形术治疗先天性肛门闭锁的疗效与经典三期手术相仿,而且方便患儿护理、缩短疗程,可以作为中高位肛门闭锁的手术选择。     

Findings of pelvic musculature and efficacy of laparoscopic muscle stimulator in laparoscopy-assisted anorectal pull-through for high imperforate anus

Background: Laparoscopic findings of levator muscle and the efficacy of laparoscopic muscle stimulator (LMS) in infants with high imperforate anus have not been reported. Methods: Twelve patients underwent laparoscopically assisted anorectoplasty for high imperforate anus. Following laparoscopic dissection of the distal rectum and division of the fistula, levator muscles in the pelvic floor were stimulated with a 5-mm-diameter LMS. Dilatation was done by inserting a guidewire and balloon catheter through the center of the levator muscle sling and muscle complex. Rectal pull-through and anastomosis between the rectum and anus were successfully completed. Results: LMS showed good contraction of levator muscles and enhanced accurate midline placement of pull-through rectum. LMS was particularly useful in observing weak muscles in infants with rectovesical fistula. Conclusions: Laparoscopy and LMS offer excellent visualization of the pelvic musculature and precise tract of rectal pull-through. Fecal continence will be assessed by long-term follow-up.     

Laparoscopically assisted anorectal pull-through for high imperforate anus: three years' experience

PURPOSE: We describe our three-year experience with the laparoscopically assisted anorectal pullthrough for high imperforate anus using laparoscopic muscle electrostimulation. MATERIALS AND METHODS: From March 2001 to January 2004, 7 patients with a diagnosis of high anorectal malformation underwent laparoscopically assisted anorectal pull-through. The patients, all males aged from 4 to 9 months (mean age, 5.8 months), presented with a rectourethral fistula. The associated malformations noted were sacral malformation, laryngeal stenosis, urethral duplication, multicystic kidney, nonpalpable testis, and esophageal atresia. All patients were treated with a colostomy in the newborn period followed by a delayed laparoscopically assisted anorectal pullthrough. Laparoscopy included stimulation of the puborectal muscle, using a modified Pe?a electrostimulator introduced through a trocar. All patients underwent a postoperative period of anal dilatation. RESULTS: In 6 cases the laparoscopically assisted anorectal pull-through was successful; there was 1 conversion to the open technique, due to strong tension from the colostomy. CONCLUSION: Although longer follow-up to evaluate continence is to come, laparoscopically assisted anorectal pull-through should be considered for the correction of the high imperforate anus and, according to our experience, it represents the gold standard. It offers the advantage of good visualization of the fistula and the surrounding structures and minimally invasive abdominal and perineal wounds.With the laparoscopic Pe?a stimulator the direct observation of the contraction of the puborectalis sling allows an evaluation of the functional contractility and an accurate colonic pullthrough in the center of the muscle complex.     

Laparoscopically assisted anorectovaginoplasty for selected types of female anorectal malformations

Purpose: The aim of this study was to describe laparoscopically assisted anorectovaginoplasty (LAARVP) for the repair of selected types of female anorectal malformation.Methods: Five cases (case 1, rectovaginal fistula with a high rectum; case 2, rectovestibular fistula with double vagina; case 3, rectovestibular fistula with absent vagina; case 4, anovestibular fistula with absent vagina; case 5, cloaca) were reviewed.Results: Patient 4 had undergone a posterior sagittal anorectoplasty without vaginoplasty at another hospital after misdiagnosis of simple anovestibular fistula. Mean age at LAARVP was 15.4 months. At LAARVP, the fistula was divided in cases 1 through 4 and dissected as low as possible in case 5. In cases 3 and 4, the distal fistula was used to create the neovagina. In cases 1 through 3, the proximal rectum was mobilized and brought through the pelvic floor sphincter muscles using Georgeson’s laparoscopically assisted colon pull-through technique through a minimal perineal incision. A posterior sagittal incision was required in cases 4 and 5. However, the initial laparoscopic approach was very helpful in both cases. Currently, all patients are well after a mean follow-up period of 32.2 months. Mean current age is 4.0 years. Patients 1 through 3 are continent, patient 4 is incontinent with soiling, and patient 5 is too young to be evaluated.Conclusions: LAARVP helps to achieve low dissection of the fistula, gives optimal view of the pelvic organs, provides accurate placement of the anorectal pull-through, and minimizes abdominal perineal scars.     

Anterior perineal approach and three-flap anoplasty for imperforate anus: optimal reconstruction with minimal destruction.

Despite progress in the treatment of imperforate anus, anal stenosis, rectal prolapse, and other late complications may still arise. In 1987, we described the three-flap anoplasty for the treatment of rectal prolapse following pull-through operations. Since 1986, we have performed 14 three-flap anoplasties in combination with an anterior perineal rectal pull-through for primary treatment of imperforate anus. The mean age at definitive repair was 4.4 months (range, 0 to 14 months). Eleven of the 14 primary pull-through procedures could be performed through a perineal approach only. There were no deaths. At a mean follow-up of 24.2 months, none of the patients has developed prolapse, and only one has had a temporary stenosis. Three children are already fully continent, and soiling is absent in 12. All have a good sphincter tone. Although it is too early to evaluate long-term results, it appears that the three-flap anoplasty prevents mucosal prolapse through the interposition of a skin-lined anal canal. Moreover, a combination of this technique with the anterior perineal approach provides an excellent exposure with minimal dissection of the perineal and pelvic musculature and allows for easy and safe pull-through of the rectal pouch, making an abdominal counterincision unnecessary in most cases. It reproduces at the same time a normal anatomy while taking advantage of all existing structures.     

Laparoscopically assisted anorectal pull-through for high imperforate anus in infants: intermediate results

Purpose

The aim of this study was to evaluate the clinical outcomes and postoperative anal function in infants with congenital high imperforate anus treated with laparoscopically assisted anorectal pull-through (LAARP).

Methods

From January 2004 to July 2007, 33 patients (28 boys and 5 girls, age ranging from 3 to 10 months) with high imperforate anus underwent LAARP. Clinical data of the LAARP group were retrospectively compared with those treated by posterior sagittal anorectoplasty (PSARP; n = 28) during the same time period. Anorectal function of these patients was evaluated using the following 3 methods: the Kelly score, anorectal vector volume manometry, and magnetic resonance imaging between the ages of 3.1 and 4.4 years.

Results

The mean operative time in LAARP and PSARP groups was 112.5 ± 12.4 and 120.4 ± 18.5 minutes (P > .05), respectively. The mean length of hospital stay in the LAARP group was shorter than that of PSARP group (11.3 ± 2.1 vs 14.6 ± 2.3 days, P < .01). No significant difference was observed between LAARP and PSARP groups regarding the Kelly score (3.52 ± 1.42 vs 3.49 ± 0.82). Although magnetic resonance imaging revealed lower malposition rates of rectum in the LAARP group than those of the PSARP group at both I-line (3.0% vs 14.3%) and M-line (3.0% vs 10.7%) levels, this was not statistically different (P > .05). Compared with the PSARP group, lower asymmetric index, larger vector volume, and higher anal canal pressure at rest and during voluntary squeeze were observed in LAARP group (P < .05). However, there were no significant differences in the length of high-pressure zone (15.2 ± 5.8 vs 15.1 ± 6.2 mm) and the presence of rectoanal relaxation reflex (84.8% vs 85.7%).

Conclusions

Satisfactory fecal continence can be achieved in patients with high-type imperforate anus after LAARP. Laparoscopically assisted anorectal pull-through has advantages over PSARP, including shorter hospital stay and better position of rectum. However, long-term follow-up is necessary to compare the benefits of LAARP against PSARP.     

Anterior perineal anorectoplasty for intermediate and high imperforate anus

Anterior perineal anorectoplasty is a new technique for the repair of high imperforate anus. This technique allows direct access and clear visualization of the puborectalis sling and rectal pouch; division of the fistula and mobilization of the rectum can be precisely performed under direct vision, thereby reducing injury to surrounding structures; the pull-through of the rectum is readily facilitated; it obviates the need to change the position of the patient during the procedure; and mobilization of the rectum required to pull the rectum through is minimal, hence the late complication of mucosal prolapse is avoided. Details of the operative procedure are described herein.     

Anterior perineal anorectoplasty for intermediate and high imperforate anus

Anterior perineal anorectoplasty is a new technique for the repair of high imperforate anus. This technique allows direct access and clear visualization of the puborectalis sling and rectal pouch; division of the fistula and mobilization of the rectum can be precisely performed under direct vision, thereby reducing injury to surrounding structures; the pull-through of the rectum is readily facilitated; it obviates the need to change the position of the patient during the procedure; and mobilization of the rectum required to pull the rectum through is minimal, hence the late complication of mucosal prolapse is avoided. Details of the operative procedure are described herein.     

Midterm follow-up study of high-type imperforate anus after laparoscopically assisted anorectoplasty

Purpose

The aim of this study was to evaluate postoperative anal function of high-type imperforate anus after laparoscopically assisted anorectoplasty (LAARP).

Methods

Between 2000 and 2002, LAARP was performed in 13 patients with high-type imperforate anus. Clinical data of the LAARP group were compared with the posterior sagittal anorectoplasty (PSARP) group (n = 7) operated before 2000. All patients were treated with initial colostomy in the newborn period. After anorectoplasty, daily glycerin enemas were given for postoperative bowel management. Anorectal function of these patients was evaluated using the Kelly score and manometry at the age of 3 to 5 years (LAARP) and 5 to 6 years (PSARP).

Results

Age at evaluation in the LAARP group was younger than that in the PSARP group (51 ± 10 vs 73 ± 12 months, P < .01). Kelly score was 3.8 ± 1.3 vs 3.4 ± 0.8, respectively. Resting pressure of internal sphincter was 31 ± 11 vs 33 ± 10 cm H₂O, respectively. Relaxation reflex of the internal anal sphincter was observed in 62% (8/13) and 29% (2/7), respectively.

Conclusions

Midterm follow-up study revealed that satisfactory fecal continence can be achieved in patients with high-type imperforate anus after LAARP. Laparoscopically assisted anorectoplasty may be a good alternative in this patient population. However, long-term follow-up is necessary to compare the benefits of LAARP against PSARP.     

Transanoproctoplasty: a 21-year review

Background

Transanal anorectoplasty was developed through the 1980s by the senior author (AB) as an alternative approach to posterior sagittal anorectoplasty for the management of imperforate anus. This study evaluates this surgical approach and its longer-term results.

Methods

Case notes of all patients treated from 1984 to 2005 were reviewed. Operative procedures, colostomy requirement, complications, and long-term outcome were recorded. Patients were grouped according to the status of the pelvic floor, the location of the rectal fistula, and the sacral ratio.

Results

A total of 245 patients (175 male, 70 female) underwent transanal anorectoplasty. The perineum was well formed in 208 patients (85%), moderately formed in 15 (6%), and poorly formed in 22 (9%) patients. Two hundred three patients (82.8%) had a visible perineal or vulval fistula, 24 (9.8%) had a prostatic urethral fistula, whereas 18 (7.4%) had a bulbourethral fistula. Overall, 6 patients (2.5%) had wound infection or breakdown. As continence is age related, 32 patients were excluded from the study. Of the remaining 212 patients, 182 are continent with no soiling or only minimal staining. Thirty patients born with a poor perineum are incontinent.

Conclusion

Transanal anorectoplasty is a safe procedure with limited morbidity. It is sphincter sparing and permits accurate placement of the rectum with its internal sphincter within the anal canal. The anus lies accurately placed at the center of the external anal sphincter muscle complex. Given a well-performed surgical intervention, eventual continence relates to the original anatomy and neurology of the pelvic floor. Transanal anorectoplasty should be regarded as an alternative rather than as a substitute to posterior sagittal anorectoplasty for reconstruction of most forms of imperforate anus.