F

Fig. 23.1 The patient is positioned transversely on the operating table, a bladder catheter is placed, and the trocars are positioned in the illustrated sites (umbilical - 5 mm, right upper and lower quadrant - 4 mm)

Keith E. Georgeson and Oliver J. Muensterer placement of the Maryland clamp. The loop ligature is then passed around the Maryland clamp and the fistula and snugged in place, adjacent to the urethra. A second loop can be placed on the rectal fistula proxi-mally in a similar fashion (Fig. 23.3). The rectum is then retracted out of the pelvis. The pubococcygeus muscle can often be visualized when it is present (Fig. 23.4). In some patients with ARM, particularly the higher lesions, the levator ani muscle is poorly developed. However, in many patients with a rectopros-tatic fistula, the muscle is quite well developed and can be seen from above with the endoscope.

A transperineal dissection follows division of the rectourethral fistula. The external anal sphincters are mapped using a transcutaneous electrostimulator. The area of maximal contraction is identified and marked appropriately with sutures. A 1-cm vertical midline incision is made at the site of the maximal muscle contraction. The intersphincteric plane is gently dissected from below the level of the levator sling up through the muscle complex bluntly (Fig. 23.5). A radially expanding trocar is then passed over a Veress needle through this intersphincteric plane and advanced between the two bellies of the pubococcygeus muscle in the midline just posterior to the urethra, using laparoscopic guidance. If the needle is inaccurately passed to either side of the midline it is readily apparent due to the laparoscopic surveillance. The Veress needle is

Fig. 23.2 After circumferential dissection of the rectum, the fistula is grasped with a Maryland clamp preloaded with a loop ligature. The fistula is then divided on the rectal side of the clamp, and the ligature is tightened around the urethral side of the clamp
Maryland Clamp
on the rectum

Pubococcygeus muscle Iliococcygeus muscle—

Pubococcygeus muscle Iliococcygeus muscle—

Pubococcygeus Muscle

Prostate

Pullthrough site

Anococcygeal raphe

Prostate

Pullthrough site

Anococcygeal raphe

Fig. 23.4 Anatomic diagram of the pull-through site in relation to the pubococcygeus muscle redirected to the correct position prior to the dilatation of the tract through the expandable trocar sleeve. The tract is dilated radially up to 10-12 mm. The rectal fistula is then grasped through the transperineal trocar and is pulled down onto the perineum trailing the trocar (Fig. 23.6). The anastomosis between the rectum and the anus is completed with a polyglycolic acid suture. The rectum is retracted cephalad laparo-scopically and secured in this retracted position with

2-0 silk sutures (Fig. 23.7). It is important to place these hitch stitches to avoid prolapse of the rectal mu-cosal wall through the anus and also to lengthen the skin-lined anal canal.

Patients are fed on the first or second postoperative day. Graduated anorectal dilatation is started 2-3 weeks after surgery. The colostomy is closed 2-3 months after the pull-through procedure is completed.

Anococcygeal Raphe
Fig. 23.5 Transperitoneal blunt dissection of the intersphinc-teric plane is performed through a 1-cm vertical incision using a clamp (the underlying external muscle complex and the pu-bococcygeus muscle are dotted)

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Constipation Prescription

Constipation Prescription

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