title: Transperineal rectovesical fistula ligation in laparoscopic-assisted abdominoperineal pull-through for high anorectal malformations.
abstract: BACKGROUND
  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.
  
  
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Pediatric Surgery Unit, Ain Shams University, Cairo, Egypt. samehhay@hotmail.com
authors.forename: Sameh Abdel
authors.initials: SA
authors.lastname: Hay
mesh_terms: D001003:Anal Canal / Q000002:abnormalities*; D006801:Humans; D007223:Infant; D010535:Laparoscopy; D008026:Ligation / Q000379:methods*; D008297:Male; D012003:Rectal Fistula / Q000601:surgery*; D012007:Rectum / Q000002:abnormalities*; D001747:Urinary Bladder Fistula / Q000601:surgery*