腹腔镜下经腹部和后矢状路联合修补术后复发性直肠尿道瘘和直肠阴道瘘

Combination of laparoscopic assisted endorectal pull-through and posterior sagittal pullthrough in repair of postoperative rectourethral and rectovaginal fistula

目的介绍腹腔镜下经腹部和后矢状路联合手术治疗直肠肛门手术后复发性直肠尿道瘘和直肠阴道瘘。方法5例术后多次复发性直肠尿道瘘或直肠阴道瘘患儿,男3例,女2例,年龄3～13岁。腹部在腹腔镜下游离结肠,远端尽可能从骶前向盆腔分离肠管,近端肠管游离保证正常结肠能无张力拖至肛门处吻合。低位盆腔肠管分离通过后矢状位切口(肛缘后上1 cm),正中切开直肠后壁,直肠内剥离黏膜至齿状线,直视下修补瘘口,近端切断结肠,将正常结肠拖出与肛门吻合。结果所有患儿排便功能良好,仅1例有轻度污粪,未见瘘管复发。结论腹腔镜下经腹部和后矢状路游离结肠、直肠,创伤小,视野清晰,避开了粘连紧密的瘘管分离,完整结肠拖出避免了瘘管的复发,后矢状路直肠切开能直视下显示并修补瘘管。

Objective Rectourethral or rectovaginal fistula is a difficult complication after anorectal surgery. The authors applied a new technique - a combined laparoscopic assisted abdominal and posterior sagittal approach in savage surgery. Methods Three boys and two girl underwent redo pullthrough for rectovaginal fistula after modified Swenson＇s procedure, perineal anorectoplasty （n = 2）, and posterior sagittal anorectoplasty （n = 3）. The age ranged from 3 to 13 years. Laparoscopic assisted abdominal dissection was performed first to mobilize colon and resect aganglionic segment down to the mid pelvis. The lower pelvic dissection was done through the posterior sagittal route leaving 1 cm of the anal canal. Extended endorectal mucosectomy was performed to the dentate line,and under direct vision the fistula was closed from inside of the rectum. The remaining mucosal cuff was everted out of the anus and the intact colon was pulled through the rectum and anastomosed to the cuff extraanally. Colostomy was done in case 2 and case 5. Results The postoperative follow-up showed no recurrent fistula,and all patients had normal voluntary bowel motions, with the exception of one child suffering from infrequent minor soiling. Conclusions Laparoscopic assisted endorectal pull-through of the intact colon can spare troublesome mobilization of the fistula and can prevent the recurrence of fistula. Rectal incision via a posterior sagittal approach provides a direct view of the fistula.