1. Laparoscopic Assisted Anorectal Pull-through Keith Georgeson Professor of Surgery University of Alabama School of Medicine

2. Pre-operative Evaluation Proximal sigmoid colostomy Proximal sigmoid colostomy Careful perineal evaluation Careful perineal evaluation Distal colostogram under pressure Distal colostogram under pressure X-rays of spine and pelvis X-rays of spine and pelvis

3. Indications for Surgery All patients with high anorectal malformations All patients with high anorectal malformations Some patients with intermediate ARMs Some patients with intermediate ARMs No patients with low ARMs No patients with low ARMs Newborn patients if level can be determined Newborn patients if level can be determined

4. Patient Positioning Supine Supine Cross table Cross table End of table End of table Body but not head elevated on sheets Body but not head elevated on sheets Firmly taped in position Firmly taped in position

5. Equipment One 5mm trocar, two 4mm trocars One 5mm trocar, two 4mm trocars Hook cautery-3mm Hook cautery-3mm Bowel grasper-3mm Bowel grasper-3mm Scissors-3mm Scissors-3mm Needle driver-3mm Needle driver-3mm Large monofilament suture Large monofilament suture Loop ligature-2 Loop ligature-2 Sleeved, Varess needle trocars (inserts 5,10,12) Sleeved, Varess needle trocars (inserts 5,10,12) Open minor instrument tray Open minor instrument tray

6. LAARP Technique

7. Goals of Lap-Assisted Anorectal Pull-Through Avoid dividing and weakening external sphincters Avoid dividing and weakening external sphincters Precise placement of rectum through external sphincters Precise placement of rectum through external sphincters Diminish perirectal scarring Diminish perirectal scarring Potential development of primary procedure avoiding colostomy Potential development of primary procedure avoiding colostomy

8. Colon Bladder Anorectal Malformations

10. Vas Ureter Laparoscopic Pull-through

12. Rectum Bladder Clip Recto-Urethral Fistula

21. Laparoscopic Pull-through

22. Alternative Approaches

25. Elements for Fecal Continence Internal sphincter competence Internal sphincter competence Rectal reservoir Rectal reservoir Anorectal angle Anorectal angle Rectosigmoid motility Rectosigmoid motility

26. Elements for Fecal Continence Sensation of rectal distention Sensation of rectal distention Anoderm anal-lined canal Anoderm anal-lined canal Anorectal reflex Anorectal reflex External sphincter competence External sphincter competence Stool consistency Stool consistency

27. PSARP PSARP does not provide superior fecal continence when compared to other pull- through operations for high imperforate anus PSARP does not provide superior fecal continence when compared to other pull- through operations for high imperforate anus Nulder, et al EJPS1995 Bliss, Tapper, et al JPS 1996 ShandlingJPS1996

28. Anorectal Function after Posterior Sagital Anorectoplasty Better anatomical positioning than older conventional operations Better anatomical positioning than older conventional operations Increased constipation Increased constipation Manometry is similar Manometry is similar Long-term function is similar Long-term function is similar Most patients need bowel management Most patients need bowel management Tsuji et al, JPS 37,2002

31. Anorectal Malformations Eventual continence is related to a positive anorectal reflex Tsuji et al, JPS 37,2002

33. Positive ARR LAR PSARP 8/9 = 89%4/13 = 30.8% P = 0.0001 Lin, et al Lin, et al

34. Lap Assisted Pull-through Time to Develop ARR LAP PSARP LAP PSARP 4.9 + 1.2 months 10.1 + 2.5 months Lin, et al Lin, et al

37. Laparoscopic Primary Pullthrough for Hirschsprung’s disease ConventionalLaparoscopic staged pullthroughprimary pullthrough

38. Mid-term Analysis for High Anorectal Malformations No difference in centrality of pull-through between Pena and Georgeson No difference in centrality of pull-through between Pena and Georgeson Muscle groups similar Muscle groups similar Continence somewhat better in G group Continence somewhat better in G group G=15, P=9 G=15, P=9

40. Laparoscopic Pull-through Surgical Anal Canal

41. Lap-Assisted Pull-Through Complications Urethral perforation Urethral perforation Diverticulum around fistular clip Diverticulum around fistular clip Rectal prolapse Rectal prolapse Missed muscle complex Missed muscle complex

42. Tips/Tricks Hitch the bladder wall with a U-stitch Hitch the bladder wall with a U-stitch Convergence of the vas deferens visually guides the surgeon to the prostate Convergence of the vas deferens visually guides the surgeon to the prostate Don’t repair small nicks in the smooth muscle Don’t repair small nicks in the smooth muscle Open the rectal fistula to confirm it’s junction with the urethra Open the rectal fistula to confirm it’s junction with the urethra Push the plastic guide of the loop ligature to the distal side of the rectourethral fistula Push the plastic guide of the loop ligature to the distal side of the rectourethral fistula The anorectal angle is straight with the thighs flexed The anorectal angle is straight with the thighs flexed

43.  Fed on first or second post-operative day  Graduated anorectal dilation started in two weeks  Colostomy closure in three months Laparoscopic Pull-through Postoperative Management

44. Goals of Lap-Assisted Anorectal Pull-Through Avoid dividing and weakening external sphincters Avoid dividing and weakening external sphincters Precise placement of rectum through external sphincters Precise placement of rectum through external sphincters Diminish perirectal scarring Diminish perirectal scarring Potential development of primary procedure avoiding colostomy Potential development of primary procedure avoiding colostomy

45. Lap Assisted Pull-through Anatomically sound Anatomically sound Leaves muscles intact Leaves muscles intact Higher incidence of ARR Higher incidence of ARR Better rectal compliance Better rectal compliance Needs long term follow-up Needs long term follow-up