Rectovesical
fistula ligation after laparoscopic mobilization of the rectum requires either cutting of the
fistula and application of endo-loop or laparoscopic endoligation or
clip application. These techniques take more time and require a well-trained surgeon for performing the
ligation laparoscopically. A simple technique for
ligation of the
fistula will be described.
MATERIALS AND METHODS: Over the last 5 years, laparoscopic-assisted abdominoperineal pull-through was performed in 12 cases with high
anorectal malformation with rectovesical or rectoprostatic
fistula. The rectovesical
fistula was mobilized initially laparoscopically. The anal site was identified using muscle stimulator and incised at its center. A Hegar dilator was passed through the center of the anal sphincter to exit behind the
fistula seen by laparoscopy. The tract was dilated with Hegar dilators till reaching a suitable size for rectal pull-through. A straight clamp holding the
ligature was passed through the perineal site and through the dilated tract to emerge on one side of the
fistula; then, the
ligature was grasped through the abdomen and turned around the junction of the
fistula, forming a loop and regrasped and brought outside with the clamp. The two ends of the
ligature emerging from the perineal site were tied, and the knot was pushed using the finger till it reached the
fistula, and then it was ligated. The
fistula was cut and the mobilized rectum was pulled through the perineal incision to be sutured at the site of the future anus.
RESULTS: Twelve patients with
imperforate anus with rectovesical or rectoprostatic
fistula had
fistula ligation with this technique. Their ages ranged from 3 to 9 months.
Ligation of the
fistula was possible in all patients.
Operative time ranged from 90 to 120 minutes (mean 110 minutes). The ascending urethrogram showed no residual
diverticulum in all but one case, which presented with difficulty in micturation and needed to be excised.
CONCLUSION: Transperineal rectovesical
fistula ligation in laparoscopic-assisted abdominoperineal pull-through for high
anorectal malformations is an alternative technique for
fistula ligation during laparoscopy. It is simple and easy to perform with acceptable postoperative results.