Kubota Akio, Kawahara Hisayoshi, Okuyama Hiroomi, Oue Takaharu, Tazuke Yuko, Tanaka Natsumi, Okada Akira
Department of Pediatric Surgery, Osaka Medical Center, Research Institute for Maternal and Child Health, Osaka 594-1101, Japan.
J Pediatr Surg. 2005 Oct;40(10):1535-8. doi: 10.1016/j.jpedsurg.2005.06.008.
BACKGROUND/PURPOSE: As minimal invasive surgery, laparoscopically assisted anorectal pull-through has been reported with new devices. However, it is not easy to create an accurate pull-through canal (PTC) because of the narrow space between the urethra and puborectal sling. The authors describe a new method using perineal ultrasonography.
The rectourethral prostatic fistula was dissected laparoscopically. Externally, electrostimulation identified the center of the muscle contraction, over which a 1.2-cm skin incision was made, and the lower part of PTC was created by hemostat forceps guided by electrostimulation. An ultrasonographic probe applied to the perineum demonstrated the urethra, and the forceps was advanced behind the urethra into the pelvic cavity using the ultrasonographic guide. Anorectal pull-through was performed after dilatation of the PTC with dilators.
The authors applied this procedure in 5 cases of male high and intermediate anomalies. Surgical damages to the urethra and the levator and vertical muscles were not encountered. Postoperative fluoroscopic study demonstrated good anterior angulation and intact contraction and relaxation of those muscles.
The combination of laparoscopic dissection, pinpointing the center of anal sphincter by electrostimulation, and identification of the urethra by ultrasonographic images from the perineum facilitated creation of appropriate PTC in the muscle complex.
背景/目的：作为微创手术，腹腔镜辅助经肛门直肠拖出术已有使用新设备的相关报道。然而，由于尿道与耻骨直肠肌襻之间的空间狭窄，创建精确的拖出通道（PTC）并非易事。作者描述了一种使用会阴超声检查的新方法。
经腹腔镜解剖直肠尿道前列腺瘘。在体外，通过电刺激确定肌肉收缩中心，在此处做一个1.2厘米的皮肤切口，并用止血钳在电刺激引导下创建PTC的下部。将超声探头置于会阴可显示尿道，然后使用超声引导将止血钳推进到尿道后方进入盆腔。用扩张器扩张PTC后进行经肛门直肠拖出术。
作者将此手术应用于5例男性高位和中位畸形病例。未出现对尿道、提肌和垂直肌的手术损伤。术后透视检查显示前向成角良好，这些肌肉的收缩和舒张功能完整。
腹腔镜解剖、通过电刺激确定肛门括约肌中心以及利用来自会阴的超声图像识别尿道，这些方法相结合有助于在肌肉复合体中创建合适的PTC。
