Hay Sameh Abdel
Pediatric Surgery Unit, Ain Shams University, Cairo, Egypt.
J Laparoendosc Adv Surg Tech A. 2009 Apr;19 Suppl 1:S77-9. doi: 10.1089/lap.2008.0157.supp.
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.
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.
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.
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.
腹腔镜下直肠游离后行直肠膀胱瘘结扎术，需要切断瘘管并应用内镜圈套器，或进行腹腔镜内结扎或夹闭。这些技术耗时较长，且需要训练有素的外科医生进行腹腔镜结扎。本文将描述一种简单的瘘管结扎技术。
在过去5年中，对12例患有直肠膀胱瘘或直肠前列腺瘘的高位肛门直肠畸形患者实施了腹腔镜辅助经腹会阴拖出术。首先在腹腔镜下游离直肠膀胱瘘。使用肌肉刺激器确定肛门部位，并在其中心切开。将一根海格扩张器经肛门括约肌中心插入，从腹腔镜所见的瘘管后方穿出。用海格扩张器扩张瘘管通道，直至达到适合直肠拖出的大小。将一把夹着结扎线的直钳经会阴部位插入并穿过扩张的通道，从瘘管一侧穿出；然后，经腹部抓住结扎线，绕过瘘管连接处形成一个环，再次抓住并随钳子带出体外。将会阴部位穿出的结扎线两端打结，用手指将结推至瘘管处，然后进行结扎。切断瘘管，将游离的直肠经会阴切口拖出，在未来肛门部位进行缝合。
12例患有直肠膀胱瘘或直肠前列腺瘘的肛门闭锁患者采用该技术进行了瘘管结扎。他们的年龄在3至9个月之间。所有患者均成功进行了瘘管结扎。手术时间为90至120分钟（平均110分钟）。除1例排尿困难需切除外，所有患者的逆行尿道造影均显示无残余憩室。
在腹腔镜辅助经腹会阴拖出术治疗高位肛门直肠畸形中，经会阴直肠膀胱瘘结扎术是腹腔镜下瘘管结扎的一种替代技术。该技术操作简单，术后效果良好。
