LAPAROSCOPIC ASSISTED PSARP FOR RECTO-BLADDERNECK AND HIGH PROSTATIC FISTULA

Contributors:  Andrea Bischoff

A video was recorded highlighting the important technical details of a laparoscopic assisted posterior sagittal anorectoplasty for recto-bladderneck fistula. The distal rectum is identified near the peritoneal reflexion, and the peritoneum around it is divided, remaining as close as possible to the rectal wall in order to avoid injuries to vas deferens, ureters, and nerves. The dissection continues circumferentially and distally to the point where it narrows down and meets the bladderneck. The fistula is divided and an endoloop is used to ligate it. Cauterization and division of avascular attachments of the rectum allows gaining of rectal length. The center of the sphincter is determined with the use of an electric stimulator and a minimal posterior sagittal incision is made with the legs elevated. A plane of dissection and a space in front of the sacrum is created, immediately behind the urethra, up to the peritoneal cavity. A laparoscopic dissection is carried out behind the bladder to meet the perineal dissection. The distal rectum is pulled down, assuring the correct orientation. When further rectal dissection is required, selective ligation of the peripheral branches of the inferior mesenteric vessels is performed. The bowel wall should be kept intact to preserve its intramural blood supply. The posterior sagittal incision is closed in layers. The posterior edge of the muscle complex is tacked to the posterior rectal wall which helps to avoid prolapse and the anoplasty is performed.