VP002 LAPAROSCOPIC AND TRANSANAL REPAIR FOR RECTAL ATRESIA

Background: Rectal atresia comprises 1% of anorectal malformations. Externally, the anus appears normal, but a blind ending web can be palpated at 2–3 cm from the anal verge. The anal canal, external sphincter and internal sphincter are well developed. There is typically no fistula between the rectum and the urethra or vagina. Few reports exist regarding investigation and repair of this anomaly. A satisfactory procedure should preserve the normally formed sphincters and anoderm and achieve postoperative continence.

Objective: The objective of this video is to present the details and outcome of a laparoscopic and transanal repair for rectal atresia.

Case Presentation: A one-day-old, 3.5 kg male presented with abdominal distension and failure to pass meconium. Plain radiographs were consistent with a distal bowel obstruction. On perineal inspection, the genitalia and anus appeared normal. Digital rectal exam, however, revealed a blind ending web at 2 cm from the anal verge. This was confirmed with a contrast enema. Further imaging did not reveal a presacral mass or genitourinary anomalies. Sacral ratio was normal.

The patient underwent colostomy and mucous fistula. The perineal muscle stimulator was used to confirm the anal opening within the sphincter muscle complex.

Post-operative mucous fistulogram confirmed the anatomy of the web and absence of a fistulous connection or duplication.

Surgical Technique: At 6 weeks of age, the infant underwent laparoscopic and transanal repair of the rectal atresia. Laparoscopic technique proceeded under general anesthesia, in mild Trendelenburg position with a foley catheter in place. Three 5 mm ports were inserted: one above the umbilicus and one at the right and one at the left iliac fossa.

Carbon dioxide insufflation was maintained at 8 mm Hg. A bladder suture was placed for better exposure of the pelvis. The web was clearly identified by gently placing a Hegar dilator into the anus. Circumferential dissection proceeded around the rectal and peritoneal attachments until the rectum was completely mobilized.

The anal canal was exposed with the Lonestar retractor. A circumferential incision was made 1-1.5 cm above the dentate line in order to preserve the anoderm. The dissection proceeded in the submucosal plane. The web was resected and an anastomosis was performed with interrupted 4-0 vicryl sutures at 1.5 cm above the dentate line in one layer. The operative time was 90 minutes.

Postoperative course: The patient was discharged on the second postoperative day. Anal dilation was started at 2 weeks after the operation and continued for 6 weeks. The colostomy was closed 2 months later. At 18 months follow-up evaluation, the patient has 2 stools daily with no fecal incontinence and the anastomosis has normal caliber.

Conclusion: The laparoscopic and transanal repair for rectal atresia is an ideal approach. The sphincters and anoderm, all elements that contribute to continence, are preserved. The laparoscopic dissection allows excellent pelvis visualization with minimal trauma. Our patient achieved a satisfactory outcome.