新生儿一期经脐单切口腹腔镜肛门成形术22例分析

One-stage single-incision laparoscopic-assisted anorectoplasty for newborns with anorectal malformationsand recto-urethral fistula

目的评估新生儿一期经脐单切口腹腔镜辅助肛门成形术（single-incision laparoscopic-assisted anorectoplaty，SILAARP）的安全性和疗效。方法回顾性分析2013年6月至2015年12月间成功施行一期SILAARP新生儿22例的临床资料。其中，直肠尿道前列腺部瘘8例，直肠尿道球部瘘14例；平均年龄42.1 h。术中经脐部2 cm切口，提出乙状结肠近端，于系膜缘对侧沿纵轴切口1 cm，置入16号肛管，经肛管注入生理盐水反复冲洗抽吸远近端肠管至胎便完全清除。细针注射器穿刺扩张小肠抽吸积气，创造腹腔镜操作空间。经脐置入1个5 mm腹腔镜和2个3 mm传统腹腔镜手术器械，行肛门成形直肠尿道瘘修补术。并与本中心以往行三期SILAARP患儿22例行疗效对比。三期SILAARP患儿中，直肠尿道前列腺部瘘6例，直肠尿道球部瘘16例，与一期SILAARP患儿比较，差异无统计学意义（P＝0.5）。结果22例患儿均成功施行一期SILAARP。平均手术时间2.4 h，腹腔镜辅助远端直肠拖出平均时间1.7 h。一期SILAARP患儿手术时间在肛门闭锁直肠尿道前列腺部瘘患儿为（1.7±0.3）h，在肛门闭锁直肠尿道球部瘘患儿为（1.9±0.4）h；与三期患儿肛门闭锁直肠尿道前列腺部瘘组1.8 h和肛门闭锁直肠尿道球部瘘组1.9 h比较，差异均无统计学意义（P＝0.62，P＝0.9）。一期SILAARP患儿中位随访时间为18个月（3～33个月），无一例发生术后并发症。术后MR证实远端直肠置于盆底肌中心。20例患儿术后第1天即有排便，2例术后便秘患儿接受1～3个月间断洗肠治疗后可自主排便。结论新生儿一期SILAARP安全有效，使肛门闭锁治疗达到生后立即根治，＂视觉无瘢痕＂的高级微创目标，能提高患儿远期生活质量。

ObjectiveCurrently staged procedures involving stoma formation and closure are the widely accepted for treating newborns with anorectal malformations （ARMs） and recto-urethral fistula.This study was intended to evaluate the safety and efficacy of one-stage single-incision laparoscopic-assisted anorectoplasty （SILAARP） as an alternative to the conventional approach.MethodsNewborns with ARMs and recto-urethral fistula undergoing one-stage SILAARP between June 2013 and December 2015 were reviewed.The procedure involved decompressing meconium via a small temporary incision of proximal sigmoid colon followed by laparoscopic-assisted pull-through.ResultsSixteen ARM newborns successfully underwent one-stage SILAARP for recto-prostatic fistula （n=8） and recto-bulbar fistula （n=14）. The mean operative age was 42.1 hours and the average operative duration was 2.4 hours.The actual pull-though time did not differ significantly from that during pull-through procedure of 3-stage control group （1.7 vs 1.9 hours）. No complications occurred during a median follow-up period of 18 （3-33） months.Postoperative pelvic magnetic resonance imaging confirmed the centrally placed rectum within muscle complex.Twenty patients started bowel movements at Day 1 post-birth.Two constipated patients periodically required an enema for 1-3 months.ConclusionsOne-stage SILAARP is both safe and effective.It provides complete rectification of ARM and recto-urethral fistula with an excellent cosmesis.