From
Colorectal Channel
Recto-Bladderneck Fistula: Laparoscopic-Assisted Anorectoplasty
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
In this case, the rectum is high, connected to the bladder, and is not reachable safely from a posterior sagittal approach alone, as shown on distal colostogram.
Port placement uses umbilical access, a 4mm trocar in the right upper quadrant for the camera, a right lower quadrant port for the surgeon's right hand, and the umbilicus for the surgeon's left hand.
A left upper quadrant port can be placed if needed to help retract the sigmoid.
The bladder is fixed to the anterior abdominal wall with a transcutaneous stay suture to provide better exposure of the pelvis.
The distal rectum is mobilized circumferentially using hook electrocautery, starting anteriorly and working laterally until posterior attachments can be visualized and released.
During rectal mobilization, both ureters and vas deferens must be identified and avoided.
A 3mm endosealer is used for attachments near the bladder to avoid thermal spread.
Great care is taken to preserve the inferior mesenteric artery and its branches, which provide intramural blood supply to the distal rectum.
The fistula is divided at the point of maximal tapering of the distal rectum near the bladder using a 3mm instrument.
Blunt dissection is used to create a space between the sacrum and the pubis.
Once the peritoneum is entered, the abdomen is insufflated and the rectum is passed into the tract.
The rectum is placed within the center of the sphincter and anchored to the posterior aspect of the sphincter complex.
An anoplasty with 16 sutures is performed, and the posterior sagittal incision is closed.
The bladder side of the divided fistula is closed with a grasper and a preloaded endo loop.
After fistula ligation, rectal length must be gained to perform anoplasty without tension.
There is no need for prone positioning; the patient's legs are placed up for the posterior sagittal portion.
The muscle complex is identified with a nerve stimulator, and a limited posterior sagittal incision is made.
The limited posterior sagittal incision allows for safer passage into the pelvis and permits tacking of the rectum to the posterior edge of the sphincter complex.