title: Two-stage laparoscopic approaches for high anorectal malformation: transumbilical colostomy and anorectoplasty.
abstract: BACKGROUND
  Trans-umbilical colostomy (TUC) has been previously created in patients with Hirschsprung's disease and intermediate anorectal malformation (ARM), but not in patients with high-ARM. The purposes of this study were to assess the feasibility, safety, complications and cosmetic results of TUC in a divided fashion, and subsequently stoma closure and laparoscopic assisted anorectoplasty (LAARP) were simultaneously completed by using the colostomy site for a laparoscopic port in high-ARM patients.
  
  
  METHODS
  Twenty male patients with high-ARMs were chosen for this two-stage procedure. The first-stage consisted of creating the TUC in double-barreled fashion colostomy with a high chimney at the umbilicus, and the loop was divided at the same time, in such a way that the two diverting ends were located at the umbilical incision with the distal end half closed and slightly higher than proximal end. In the second-stage, 3 to 7 months later, the stoma was closed through a peristomal skin incision followed by end-to-end anastomosis and simultaneously LAARP was performed by placing a laparoscopic port at the umbilicus, which was previously the colonostomy site. Umbilical wound closure was performed in a semi-opened fashion to create a deep umbilicus.
  
  
  RESULTS
  TUC and LAARP were successfully performed in 20 patients. Four cases with bladder neck fistulas and 16 cases with prostatic urethra fistulas were found. Postoperative complications were rectal mucosal prolapsed in three cases, anal stricture in two cases and wound dehiscence in one case. Neither umbilical ring narrowing, parastomal hernia nor obstructive symptoms was observed. Neither umbilical nor perineal wound infection was observed. Stoma care was easily carried-out by attaching stoma bag. Healing of umbilical wounds after the second-stage was excellent. Early functional stooling outcome were satisfactory.
  
  
  CONCLUSIONS
  The umbilicus may be an alternative stoma site for double-barreled colostomy in high-ARM patients. The two-stage laparoscopic approaches for high-ARM, TUC and stoma closure with simultaneously LAARP are both technically feasible and safe with excellent cosmetic result.
authors.affiliation: Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
authors.forename: Li
authors.initials: L
authors.lastname: Yang
authors.affiliation: Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China. Electronic address: tshaotao83@126.com.
authors.forename: Shao-Tao
authors.initials: ST
authors.lastname: Tang
authors.affiliation: Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
authors.forename: Shuai
authors.initials: S
authors.lastname: Li
authors.affiliation: Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
authors.forename: T H
authors.initials: TH
authors.lastname: Aubdoollah
authors.affiliation: Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
authors.forename: Guo-Qing
authors.initials: GQ
authors.lastname: Cao
authors.affiliation: Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
authors.forename: Hai-Yan
authors.initials: HY
authors.lastname: Lei
authors.affiliation: Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
authors.forename: Xin-Xing
authors.initials: XX
authors.lastname: Wang
mesh_terms: D001003:Anal Canal / Q000601:surgery*; D000714:Anastomosis, Surgical / Q000379:methods; D000071056:Anorectal Malformations; D001006:Anus, Imperforate / Q000601:surgery*; D003125:Colostomy / Q000379:methods*; D005260:Female; D006801:Humans; D007223:Infant; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D019651:Plastic Surgery Procedures / Q000379:methods*; D012007:Rectum / Q000601:surgery*; D012189:Retrospective Studies; D014472:Umbilicus
keywords: Anorectal malformations; Anorectalplasty; Laparoscopy; Trans-umbilical colostomy