Laparoscopy-assisted Anorectoplasty with Coloplasty for Type-I/II Congenital Pouch Colon

Abstract

Laparoscopy-assisted anorectoplasty (LAARP) with coloplasty is presented in two infants as a feasible technique for managing Type I/II congenital pouch colon (CPC). These key steps include laparoscopic fistula division, pouch mobilization, extracorporeal coloplasty, and perineal pull-through. The patients have shown good functional outcomes in the follow-up, supporting the role of minimally invasive approaches in selected CPC cases.

INTRODUCTION

Laparoscopy-assisted anorectoplasty (LAARP) is increasingly utilized in the management of high anorectal malformations in male patients, particularly those with recto-vesical or recto-prostatic urethral fistulas.[1] However, the application of LAARP in the surgical management of congenital pouch colon (CPC) remains infrequently reported.[2] Coloplasty is now increasingly used in cases of CPC with improved functional outcomes.[3] Coloplasty reduces redundancy, improves peristalsis, and preserves colonic length for its absorptive function.[4]

Herein, we describe the surgical technique of LAARP combined with coloplasty in two cases of Type I CPC, with acceptable functional outcomes. This technique was demonstrated during the Karl Storz Award session at the 19^th National Conference of Pediatric Endoscopic Surgeons of India, held in Agra in March 2024.

SURGICAL CONSIDERATIONS

1. Precise delineation of the anatomy, including identification and dissection of the pouch and the colo-vesical/colo-vestibular fistula

2. Division of the colo-vesical fistula, ensuring no large diverticulum is left behind

3. Coloplasty to tubularize the pouch while preserving its delicate vascular supply

4. Accurate delineation of pelvic musculature and placement of the tubularized colon in the center of the sphincter complex.

CASE DESCRIPTION

Case 1

A 3-day-old boy was referred to us with an imperforate anus and gross abdominal distension. He underwent a loop ileostomy for Type I CPC with colo-vesical fistula at the bladder neck.

Case 2

A 6-month-old girl presented to us with an imperforate anus and passage of stools from the vestibule. She underwent pan-endoscopy with loop ileostomy for Type II CPC. The pouch was opening in the vestibule between 2 hemivaginas.

Both infants were thriving well after diversion and were then planned for LAARP with coloplasty after a detailed work-up. A preoperative distal loopogram confirmed the type of CPC and the anatomical details [Figure 1a]. The bowel was prepared with PEGLEC solution a day before surgery.

Figure 1.

(a) Preoperative distal loopogram showing type-1 congenital pouch colon (CPC) with colo-vesical fistula, (b) Laparoscopy port positions, (c) Laparoscopic image showing anatomy of CPC, fistula, and urinary bladder, (d) Laparoscopic image showing narrow beak-like fistula entering into bladder neck, (e) Laparoscopic image showing division of colo-vesical fistula after ligation, and (f) Laparoscopic image showing dissection of presacral space till levator diaphragm

TECHNIQUE

The patient was positioned in a supine-lithotomy position. A 5 mm optical port was introduced in the left subcostal region, and two 3 mm working ports were placed at the umbilicus and left lower quadrant [Figure 1b and Video]. After adhesiolysis, the bladder was hitched, and the pouch was carefully dissected circumferentially until it tapered into a narrow, beak-like fistula at the bladder neck (Case 1) [Figure 1c and d] or into the vestibule (Case 2). The fistula was doubly ligated using 3-0 polyglactin sutures and then divided [Figure 1e].

The peritoneal reflection was opened, and dissection continued in the presacral space until the levator muscle was clearly visualized [Figure 1f]. The pouch, preserving its tenuous blood supply, was mobilized and delivered extracorporeally through an extended left lower quadrant port site. Coloplasty was performed over a Hegar’s dilator using a linear stapling device [Figure 2a and b]. The tubularized colon was then returned to the abdominal cavity, and pneumoperitoneum was re-established.

Figure 2.

(a) Tubularized coloplasty performed over an adequately sized Hegar’s dilator, (b) Completed coloplasty, (c) 10 mm port introduced through the center of the muscle complex into the abdomen, and (d) Completed anoplasty

A limited sagittal perineal incision was made, and the muscle complex was divided in the midline. Under laparoscopic guidance, a 10 mm port was inserted at the center of the muscle complex into the abdominal cavity, through which the tubularized colon was pulled down [Figure 2c]. The pull-through segment was secured to the muscle complex and presacral fascia using 4-0 polyglactin sutures to prevent prolapse. The perineal body and muscle complex were reconstructed, followed by anoplasty using 5-0 polydioxanone sutures [Figure 2d]. In Case 2, the two hemivaginas were anastomosed together as a single cavity with absorbable sutures after excising the vestibular end of the colovesical fistula. Mesenteric windows were closed, and bowel orientation was confirmed.

The operative time for Cases 1 and 2 was 240 and 300 min, respectively, with minimal blood loss and no intraoperative complications [Table 1]. The postoperative course was uneventful. Following stoma closure, both patients initially experienced increased stool frequency; however, by 1 year of age, they were passing 3–4 well-formed stools daily with no perineal excoriation. Follow-up at 27 and 32 months, respectively, revealed occasional (Krickenbeck Grade 1) soiling in both patients, no constipation in Case 1, and occasional constipation relieved with laxatives (Krickenbeck Grade 2) in Case 2 [Table 1]. The neo-anus appeared healthy, and distal loopogram showed no evidence of recurrent dilation in both infants.

Table 1.

Details of patients who underwent laparoscopy-assisted anorectoplasty with Coloplasty

Variables		Case-1		Case-2
Age (months)		6		14
Sex		Male		Female
Type of congenital pouch colon		Type-I		Type-II
Type of fistula		Colo-vesical fistula		Colo-vestibular fistula
Associated anomalies		-		Malrotation of Gut
Operative time (min)		240		300
Blood loss		Minimal		Minimal
Complications		Nil		Nil
Follow-up duration (months)		27		32
Outcome assessment (Krickenbeck)
Voluntary bowel movements		Cannot be assessed as age <3 years		Cannot be assessed as age <3 years
Soiling		Grade 1		Grade 1
Constipation		No constipation		Grade 2 (require laxative)

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.