Perineal Dissection Research Articles

Hartmann's procedure in rectal cancer: a population-based study of postoperative complications.

Hartmann's procedure for rectal cancer patients is increasingly performed but few studies have reported the postoperative outcome. The purpose was to report postoperative complications and analyse risk factors in rectal cancer patients operated with Hartmann's procedure. To describe the selection and postoperative complication patterns, all bowel-resected rectal cancer patients were included. Population-based data were from the county of Västmanland, Sweden. All rectal cancer patients operated with an elective bowel resection between 1996 and 2012 were included. Demographics and postoperative complications were prospectively registered and data retrospectively analysed. Of the 624 patients included, 396 (64%) were operated with an anterior resection, 159 (25%) with an abdominoperineal excision and 69 (11%) a Hartmann's procedure of which 90% were low Hartmann's. Patients operated with a Hartmann's procedure were significantly older, had higher ASA-score, poorer WHO performance score and lower serum albumin levels. Operative time for Hartmann's procedure was a median of 49 and 99 min shorter than after anterior resection and abdominoperineal excision, respectively, and entailed less bleeding. Complications related to the pelvic and perineal dissections were more common after abdominoperineal excision compared with anterior resection and Hartmann's procedure (32 vs. 9 and 13%, p < 0.001). Few rectal cancer patients, operated with Hartmann's procedure, developed pelvic complications despite a higher age, more co-morbidities, metastases in different localities and functional inferiority when compared with the patients operated with anterior resection or abdominoperineal excision. Hartmann's procedure is a valid alternative procedure in the old and frail rectal cancer patient.

Incisional negative pressure wound therapy decreases the frequency of postoperative perineal surgical site infections: a cohort study.

Abdominoperineal resection is a procedure associated with high rates of perineal surgical site infections, causing distress to the patient, costs to the hospital system, and delays in further treatment. The aim of this study was to investigate the role of incisional negative pressure wound therapy in decreasing the rates of perineal surgical site infection. This retrospective cohort study had a historical, consecutively sampled control group. This study was conducted at a single-institution tertiary care academic institution. All patients undergoing an abdominoperineal resection between 2008 and 2012 were assessed. Perineal incisional negative pressure wound therapy was applied to all patients following an abdominoperineal resection between 2010 and 2012 at 125 mmHg continuous suction for 5 days postoperatively. The development of a perineal surgical site infection within the first 30 days postoperatively was the primary outcome measured. Fifty-nine patients were included: 27 in the incisional negative pressure wound therapy group and 32 in the control group. A statistically lower proportion of perineal surgical site infections were detected in the incisional negative pressure wound therapy group than in the standard dressing group (15% vs 41%; p = 0.02). Both populations were similar in perioperative risk factors, with the exception of increased levels of blood urea nitrogen, a higher proportion of hypertensive patients, and a longer mean operative time in the incisional negative pressure wound therapy group. Additionally, an increased length of stay was observed in the incisional negative pressure wound therapy group (11 vs 8 days; p = 0.03). After adjusting for confounders, including the type of perineal dissection, incisional negative pressure wound therapy was found to be an independent predictor of not developing an surgical site infection (adjusted OR, 0.11; 95% CI, 0.04-0.66; p = 0.01). The study's retrospective nature limits the results because of the risk of interpreter bias, although this was addressed in part by reviewing data in duplicate. We controlled for the potential for selection bias with our consecutive sampling model. Our study demonstrates a role for incisional negative pressure wound therapy in decreasing rates of perineal surgical site infection following abdominoperineal resection. Prospective randomized trials will be required to further investigate this intervention.

Following the Needles: An Anatomical Study to Evaluate the Postoperative Safety and Symptoms of Patients Receiving a Transobturator Male Sling Implant

Implanting a transobturator male sling is a valid option to manage urinary incontinence after prostatectomy. We evaluated the trajectory of Argus T™ needles blindly introduced into the retropubic space to determine the safety and etiology of postoperative symptoms that can arise from this implant. Needles were implanted and perineal dissection was performed in 20 fixed, adult human male cadavers. The distance was measured from the upper and lower extremities of the needles in the internal pelvic wall upto the obturator neurovascular bundle. Anatomical variations identified in this area proximal to the needles were characterized. The inguinocrural region was also dissected from the needles positioned there. Statistical analysis of the results was done. All needles transfixed the obturator internus muscle. Of the needles 90% were completely immersed in its fibers and not visible in the inner wall of the pelvis. The distance to the obturator neurovascular bundle and anatomical variations were noted. In the inguinocrural region the pectineus and adductor longus muscles were perforated in all cadavers. The needle sling implant preserves the obturator neurovascular bundle and obviates the potential for postoperative pelvic hematoma. The anatomical trajectory of the needles used for this implant account for the groin and perineal pain side effects. Based on similarities between the Argus T and other types of outside-in transobturator male slings the results of the current study could be extrapolated to the latter slings.

No observable difference in operative oncological outcomes between extra-levator versus standard abdominoperineal excision

In recent years, concerns have arisen regarding the poorer outcomes of patients undergoing abdominoperineal excision (APE), compared with those having total mesorectal excision (TME). This was attributed to higher rates of involved circumferential resection margins (CRMs) and tumour perforations after APE, and was thought to have occurred due to adherence of the TME plane to the puborectalis sling. This apparent disparity was addressed by the re-introduction of a more radical approach to APE surgery, which closely mirrored the operation described by Miles [1]. The procedure, extra-levator abdominoperineal excision (ELAPE), entails a more extensive, wider perineal dissection down to the origin of the levators. Several retrospective studies have reported a reduction in rates of CRM positivity and intraoperative perforation with ELAPE, compared with standard APE (SAPE). Each of these histopathological findings is deemed a crucial marker in determining prognosis for low rectal cancer. Thus, pathological assessment of the resected specimen, as a surrogate marker of oncological superiority, can also be used as a surrogate marker for long-term outcome. Although the loco-regional clearance obtained by ELAPE may be superior to SAPE, the substantial perineal defect, which is often too large for primary closure, can result in delayed wound healing and perineal herniation. Asplund [2] compared outcomes for 158 patients with low rectal cancer, half of whom underwent SAPE and half ELAPE. No advantage for ELAPE was shown, in terms of local recurrence, intraoperative perforation and CRM positivity, but higher rates of perineal wound complications were reported. This is in contradiction to other studies demonstrating higher rates of CRM positivity and intraoperative perforations with SAPE. Having adopted the ELAPE technique (performed with the patient in the prone position), we sought to ascertain whether the wider cylindrical dissection offers any oncological advantage over SAPE, through comparing the pathological findings of our resected specimens. We studied 34 consecutive patients who underwent APE: 17 underwent SAPE and 17 ELAPE. The results are outlined in Table 1. There was no difference in patient demographics or tumour T stage between the two groups. Similar proportions of patients in each group had received preoperative radiotherapy, ELAPE: 71 % (12) and SAPE: 88 % (15) (p = 0.40). The mean distance to the CRM did not differ between groups, ELAPE: 6.5 mm and SAPE: 5.8 mm (p = 0.80), nor did the R0 resection rate, ELAPE: 82 % (14) SAPE: 71 % (12) (p = 0.69). There was 1 intraoperative tumour perforation in the ELAPE group (6 %), and 2 (12 %) of the SAPE specimens were perforated (p = 1.00). Comparable mean numbers of lymph nodes were harvested (ELAPE: 8.9 and SAPE: 8.6) (p = 0.90). Throughout the period, that ELAPE was performed tumour perforation, and R1 or 2 resections occurred sporadically and did not correlate with a perceived learning curve. We have not detected any difference in short-term surrogate markers for oncological outcome between ELAPE and SAPE. Our numbers are small; however, the results mirror those of Asplund et al. [2] who reported a specimen perforation rate of 13 % (ELAPE) versus 10 % (SAPE), and CRM positivity of 17 and 20 %, respectively. The Asplund study failed to find any oncological advantage of K. J. Gash (&) L. Cooper N. Smart R. Longman M. Thomas University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW, UK e-mail: kat_jg@hotmail.com

Prone Jackknife Position Is Not Necessary to Achieve a Cylindrical Abdominoperineal Resection

This video demonstrates a laparoscopic abdominal perineal resection for a fixed 4.8-cm mass involving the posterior and left rectal walls and left puborectalis, 2 cm from the anal verge (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A127). We detail the steps of the procedure, all completed in lithotomy, including lateral-to-medial dissection; identification and protection of the left ureter and presacral nerves; division of the inferior mesenteric artery; medial-to-lateral dissection, with meeting the previous dissection plane; total mesorectal excision and pelvic dissection; perineal dissection and layered closure; and abdominal inspection and colostomy creation. Total operative time was 181 minutes. The specimen total mesorectal excision was complete with a negative circumferential radial margin (greater than 1 cm). Final pathology was T3N2M0.

Perineal Wound Healing Following Ileoanal Pouch Excision

IntroductionThere is paucity of information relating to perineal wound healing when pouch failure after ileal pouch anal anastomosis necessitates pouch excision (PE). The aim of this study is to evaluate perineal healing and factors associated with the development of persistent perineal sinus (PPS) after PE. MethodsPerineal wound-related outcomes for patients who underwent PE from 1985–2009 were evaluated by type of closure (extrasphincteric, intersphincteric, and sphincter-preserving (SP)) and other factors (presence of Crohn's disease (CD) and/or perineal fistulae). Primary outcomes were PPS and delayed healing (healing after PPS development). ResultsOne hundred ten patients (CD 48 %) underwent PE. PPS occurred in 39.8 % patients, 51 % had delayed perineal healing with further procedures, with an overall healing rate of 80.7 %. Closure technique was not associated with PPS (p = 0.37) or eventual healing (p = 0.94). For CD patients, risk of PPS (41 vs. 39 %, p = 0.83) and delayed healing (44 vs. 59 %, p = 0.61) was similar to non-CD patients, but uncomplicated healing took longer (p = 0.04). Four of 15 (26.7 %) patients who underwent SP closure developed PPS; all eventually healed with secondary sphincter excision. ConclusionsPerineal healing may be prolonged after pouch excision. Since eventual healing can be achieved in most patients, perineal dissection and closure can be tailored to the individual circumstance. Sphincter preservation may be used in non-CD patients if future reconstruction is possible. Extrasphincteric closure is preferable with cancer or perineal sepsis. Sphincter resection allows for complete healing in patients who undergo SP dissection and develop PPS.

Robotic Abdominoperineal Resection for Lower Rectal Cancers: How We Do It?

Abstract Introduction: Robotic approach has been increasingly applied to the surgical resection of distal rectal cancer. All reports from the advocators on the use of robotic assistance in rectal s...

Use of an endorectal mucosal advancement flap to treat H-type rectovestibular fistula in patients with a normal anus

The combination of an H-type rectovestibular fistula (RVF) and a normal anus is a rare type of anorectal malformation, resulting in abnormal communication between the normal rectum and vestibule in girls. Among the surgical methods used to treat this condition are simple fistula resection and extensive perineal dissection, but postoperative fistula recurrence is frequent. We utilized the endorectal mucosal advancement flap technique on three patients with H-type RVFs and a normal anus, all of whom had favorable outcomes.

Y-type urethral duplication in children: Management strategy at our center

Aims:Report of seven children with Y-type urethral duplication (YUD).Materials and Methods:(A) Four staged operations were performed in patients having extensive perineal dissection (for rectourinary fistula separation and anterior mobilization of ventral urethra (VU)), tension rectocutaneous anastomosis, and children who were not toilet trained). These stages are (1) diversion sigmoid colostomy with anterior mobilization of VU as perineal urethrostomy via anterior sagittal approach; (2) Orthotopic urethral (OU) reconstruction; (3) anastomosis of OU and perineal urethra; (4) colostomy closure with management of complications. (B) The patients having VU onto the perineum underwent single stage urethral reconstruction.Results:The VU was urethrorectal/urethroanal in five and urethroperineal in two. Low anorectal malformation and upper urinary tract anomalies were present in 57.1% (4/7) and 14.7% (1/7) patients, respectively. Buccal mucosa free graft, transverse inner preputial flap, and perineal skin were tubularized for OU reconstruction. Mean age at 1st , 2nd , 3rd , and 4th surgery was 5 ± 0.78, 28 ± 0.78, 36 ± 0.78, 49 ± 0.78 months respectively. Three patients needed surgery for complications (urethrocutaneous fistula in two and urethral diverticulum in one) in a mean 3.12 ± 0.34 years of follow-up. Final uroflowmetry and fecal continence were good in all patients.Conclusions:The YUD is a difficult entity to manage. Although, staged procedure appears to be time consuming, but good and promising results can be achieved by staging the procedure.

Robotic-Assisted Extralevator Abdominoperineal Resection in the Lithotomy Position: Technique and Early Outcomes

Extralevator abdominoperineal resection (E-APR) has been advocated as a superior procedure to achieve negative circumferential resection margins (CRMs) for sphincter-invading rectal cancers. An open total mesorectal excision is performed followed by perineal dissection with resection of the levators in the prone position. We describe a novel minimally invasive robotic approach carried out in the lithotomy position. Using the robotic arms to dissect the rectum and divide the levator fibers at their origin, the dissection is carried out in the ischiorectal space as distally as possible. From May to July 2011, six cases of robotic E-APR for rectal cancer were performed. The mean age was 54.5 years old. Mean operating time was 335 minutes. Mean estimated blood loss was 250 mL. There were no conversions to the open approach. A cylindrical specimen was obtained in all patients without perforation. All CRMs were negative. Mean hospital stay was 5 days. Two patients developed perineal wound infections and one developed a small bowel obstruction postoperatively. Robotic-assisted E-APR performed in the lithotomy position is safe and feasible. Future studies are needed to define the benefits of this technique.

Debate and update issues for surgical treatment of mid and lower rectal cancer

Updates and Debate issues form the surgical treatment of middle or low rectal cancer The main goals for the surgical treatment of rectal cancer were the complete removal of the rectal cancer with surrounding lymphatic draining area, which subsequently result in decreasing the rate of local recurrence as well as prolong patient survival. If the tumor located at the near the anal canal, concerning issues will be whether anal sphincter can be preserved or not and furthermore autonomic pelvic nervous system could be saved or not. Multidisciplinary approach for rectal cancer has been more popular and treatment strategy rapidly changing based on more accurate preoperative local staging finding and minimal invasive surgical techniques become popular too. One of the advance technology is the development of transanal local excision techniques such Transanal endoscopic microsurgery technique such as TEM(transendoscopic microsurgery), TEO(transendoscopic operation) and TAMIS (transanal minimal invasive surgery). Those techniques make us be able to excise early rectal cancer with full thickness as well as unfragmented state, also can be approached to the upper rectum, which can not approach with previous conventional transanal approach method. Local excision for early T1 rectal cancer has been regards as good treatment option because patient can avoid complication related to the radial proctotectomy such as anastomoitc leakage, postoperative sexual and voiding dysfunction and dysregulated bowel movements. Neoadjuvant chemoradiation therapy has been recommended for patient with cT3N0 or cT3 N+ rectal cancer because some clinical trials showed us preoperative chemoradiation therapy showed better local control rate and less toxicities than postoperative chemoradiation treatment. Recent clinical trial both retrospective and prospective showed us a promising results about local excision after neoadjuvant chemoradiation selectively in patients with low rectal cancer. Neoadjuvant chemoradiation therapy for cT2N0 followed by local excision reported excellent oncologic outcomes quite comparable to the radical surgery group. In addition to that, there has been some reports which showed clinical complete remission after neoadjuvant chemoradiation therapy could be wait and see. A couple of observational studies showed wait and see can be possible option of treatment in selective patients. Radial surgery for middle and low rectal cancer still remains a cornerstone of surgical treatment Ultralow anterior resection with or without intersphincteric resection became a more standard surgical method for low rectal cancer. Oncologic and functional outcomes has been reported as safe even functional outcomes study was rare. Furthermore, Abdominoperineal resection has been famous for high intraoperative tumor perforation and positive circumferential resection margin, those factors have been contributed to the high rate of local recurrence and poor survival rate compared with sphincter saving procedures for rectal cancer. Recently, there have been great efforts for reducing theses problem and total levator excision or extended abdominoperineal resection concepts emerged. Surgeons who advocated this concept recommended perineal dissection under the Jack-knife position. Surgical management for low rectal cancer should be directed for radically and preserving function based on multimodality approach. We need more high level of evidence based on prospective clinical trials for tailored treatment of rectal cancer patients

A Modified Posterior Pelvic Exenteration Technique in a Woman: (A Simplified Method With Using Transvaginal Way)

We represent a simplified surgical method for posterior pelvic exenteration in a woman by using the transvaginal way in addition to classic abdominal approach. A modified posterior pelvic exenteration technique was performed in a patient with bulky pelvic tumor. The transvaginal way was used for the deep perineal dissection when the abdominal dissection was arrested. An ultralow coloanal anastomosis was completed by using the transvaginal way. After the recovery period, the patient was discharged from hospital without any complication. The transvaginal access should be reminded in the circumstances of the abdominal dissection arrested in posterior pelvic exenteration operations in women.

Laparoscopic extralevator abdominal perineal excision of the rectum: the best of both worlds

We report a combined laparoscopic and open technique for extralevator abdominal perineal excision of the rectum. The key steps are a laparoscopic rectal dissection limited distally by the coccyx. The open, prone, perineal dissection affords excellent views and allows a cylindrical specimen to be obtained. The resulting perineal defect is closed by a biological mesh. Extralevator abdominal perineal excision of the rectum offers a superior oncological specimen with reduced circumferential resection margin involvement compared to traditional techniques. Combined with a laparoscopic approach, this also has the potential to improve postoperative recovery and reduce morbidity.

Where does pelvic nerve injury occur during rectal surgery for cancer?

Optimal treatment of rectal adenocarcinoma involves total mesorectal excision with nerve-preserving dissection. Urinary and sexual dysfunction is still frequent following these procedures. Improved knowledge of pelvic nerve anatomy may help reduce this and define the key anatomical zones at risk. The MEDLINE database was searched for available literature on pelvic nerve anatomy and damage after rectal surgery using the key words 'autonomic nerve', 'pelvic nerve', 'colorectal surgery', and 'genitourinary dysfunction'. All relevant French and English publications up to May 2010 were reviewed. Reviewed data were illustrated using 3D reconstruction of the foetal pelvis. The ligation of the inferior mesenteric artery and dissection of the retrorectal space can cause damage to the superior hypogastric plexus and/or hypogastric nerve. Anterolateral dissection in the 'lateral ligament' area and division of Denonvilliers' fascia can damage the inferior hypogastric plexus and efferent pathways. Perineal dissection can indirectly damage the pudendal nerve. In most cases, the pelvic nerves can be preserved during rectal surgery. Complete oncological resection may require dissection close to the nerves where the tumour is located anterolaterally where it is fixed and when the pelvis is narrow.

Perineal and Pelvic Anatomy of Extralevator Abdominoperineal Excision for Rectal Cancer: Cadaveric Dissection

Circumferential margin positivity and tumor perforations are the main reasons for the poor oncological outcome following standard abdominoperineal excision for low rectal cancer. The extralevator abdominoperineal excision approach has been developed to avoid "coning down" or "surgical waisting"; however, surgical education in this area has been neglected. This study aims to define correct surgical anatomical planes for extralevator abdominoperineal excision and show the differences in excision planes between standard and extralevator abdominoperineal excision. Macroscopic surgical dissections were performed in a clinical anatomy laboratory. The dissections were recorded as video clips. In accordance with the surgical technique of extralevator abdominoperineal excision, abdominal and then perineal dissections were performed on 1 female and 5 male cadavers. Neurovascular, muscular, and fascial structures located in or near the excision field were carefully revealed. The surgical planes of extralevator abdominoperineal excision, which widen the tumor-free margins and prevent inadvertent bowel perforation, are described in this step-by-step anatomical dissection study. Within the surgical excision planes, sacral vessels and sympathetic chains form a neurovascular network at the level of the sacrococcygeal joint. Although pelvic autonomic plexuses were away from the lateral incision line, their branches extending to urogenital organs were very close to the anterolateral dissection line. Perineal dissection showed that the internal pudendal vessels and pudendal nerve were close to the lateral excision plane. The superficial transverse perineal muscle and perineal body were the most important landmarks to determine the anterior boundary of dissection. The study focused on the perineal dissection of extralevator abdominoperineal excision. Successful extralevator abdominoperineal excision crucially depends on an accurate knowledge of surgical anatomical planes.

Laparoscopic Management of Congenital H-Type Urethroanal Fistula

Laparoscopic management in a case of congenital urethroanal fistula with a normal anterior urethra in a 5-month-old male child is reported. A congenital H-type urethroanal fistula is a rare entity. Management of such fistula has always been surgical, ranging from perineal dissection, posterior saggital approach, to abdomino-perineal approach. We describe a minimally invasive laparoscopic method for approaching such fistula, which has not been described in the literature and is being reported for the first time.

Anterior-entry Abdominoperineal Resection: A Variation in the Method of Perineal Dissection

For patients with rectal cancer, there is a greater risk of a positive radial margin or local tumor recurrence when an abdominoperineal versus low anterior resection is performed, or when tumors are in an anterior versus nonanterior location. In response, clinical leaders have encouraged perineal dissection in the prone position or in concert with a coccygectomy. We describe anterior-entry abdominoperineal resection, which may minimize the need for such maneuvers and negative patient outcomes. Anterior-entry abdominoperineal resection was provided by one surgeon to 10 patients over an 18-month period. Pelvic dissection used total mesorectal excision techniques. Anteriorly, in men, the perineal dissection occurred between the external anal sphincter and the bulbospongiosus and transversus perinei superficialis muscles. Initial entry into the pelvis occurred anteriorly under direct vision. Rectal specimen quality was graded out of 5 using Quirke methods. There were 8 male and 2 female subjects with a median age of 65 years. Eight of 10 tumors had some component of an anterior location. Seven patients received preoperative radiation. The radial margin was positive in 1 case. Median Quirke score for quality of the surgical specimen was 5 of 5. Anterior-entry abdominoperineal resection follows anatomic planes in the perineum and demands initial entry into the pelvis anteriorly and under direct vision. It may minimize rates of positive radial margins, may be especially suited for tumors with a locally advanced anterior component, and in many patients may avoid the need for perineal dissection in the jackknife position.

Focus on Extralevator Perineal Dissection in Supine Position for Low Rectal Cancer Has Led to Better Quality of Surgery and Oncologic Outcome

After abdominoperineal excision (APE), the presence of tumor cells in the circumferential resection margin (R1) and iatrogenic tumor perforations are still frequent and result in an increased rate of local recurrences. In this study, a standardized supine APE with an increased focus on the perineal dissection (sPPD) is compared to the customary supine APE. From 2000 to 2010, a total of 246 patients underwent APE for rectal cancer (sPPD and customary supine APE). All patients were staged with preoperative magnetic resonance imaging (MRI) and received neoadjuvant treatment (n = 203) when margins were involved or threatened (cT3 + and T4). As a result of a quality improvement program in 2006, the surgical technique was modified: it became standardized, emphasis was placed on the perineal dissection, and pelvic dissection was limited to avoid false routes when following the total mesorectal excision planes deep into the pelvis. Overall, the percentage of involved circumferential resection margins (CRMs) was 10%. In the period before introducing sPPD, the R1 percentages for cT0-3 and cT4 tumors were 6.8 and 30.2%, compared to 2.2 and 5.7% after introduction of sPPD (P = 0.001). Risk factors for R1 resection were preoperative T4 tumors (14.9%, P = 0.011), tumor perforation (33.3%, P = 0.002), fistulating tumors (35.7%, P = 0.002), mucus-producing tumors (23.1%, P = 0.006), or bulky tumors (66.7%, P < 0.001). The objective of surgical treatment of low rectal cancer is to obtain negative resection margins and subsequently reduce the risk of local recurrence. A combination of the appropriate preoperative treatment and standardized surgical technique such as sPPD can achieve this goal.

Surgical methods in the treatment of congenital anomalies of the uterine cervix

Cervical agenesis is an extremely rare congenital anomaly of the female reproductive tract. There are many anatomical forms that constitute this type of cervical abnormality and the literature is replete with attempts to surgically restore a patent outflow tract and preserve fertility in these patients. There are no carefully designed cohort or randomized trials to support a best surgical practice; past reports are descriptive only. Of late, there has been renewed interest in the surgical treatment of cervical dysgenesis with techniques both through laparotomy with hysterotomy and more recently, minimally invasive approaches, which have attempted to restore a patent outflow tract without perineal dissection or graft harvesting in an attempt to avoid uterovaginal scarring if further surgery is necessary. To maintain consistency in the field of surgical reconstruction of the female reproductive tract, there has been a call for streamlined classifications of the anatomical abnormalities observed to better compare patient findings and the outcome of their surgical reconstruction in the literature. The authors discuss the embryological development of this rare reproductive tract abnormality and have proposed a systematic surgical strategy for each anatomic finding. Ultimately, counseling patients on the best surgical approach requires a discussion on the potential postoperative complications, the degree of cervical abnormality, and the patient's desired treatment outcome. Whether the patient desires definitive treatment with a hysterectomy to avoid the risk of further surgery or, when anatomically appropriate, she wants to pursue a patent outflow tract and the possibility of future childbearing, evidence-based medicine must become the source for surgical strategies.

Single-Incision Laparoscopic Endorectal Pull-Through (SILEP) for Hirschsprung Disease

BackgroundOver the last 15 years, the laparoscopic-assisted endorectal pull-through procedure first described by Georgeson has become the standard treatment for Hirschsprung disease in many centers around the world. We report the first six patients who were operated using a single-incision endosurgical approach. MethodsSix infants (one female) diagnosed with Hirschsprung disease underwent laparoscopic endorectal pull-through via a single 1 cm horizontal skin incision in the umbilicus. Firstly, laparoscopic seromuscular leveling biopsies of the rectum and sigmoid were obtained. The affected rectosigmoid colon and rectum was then mobilized distally beyond the peritoneal reflection, facilitating the subsequent perineal dissection, pull-through, and coloanal anastomosis. Operative variables were compared between single-incision and conventional laparoscopic endorectal pull-through. ResultsThe patients’ average age and weight was 28 days and 3.8 kg, respectively. Operative time ranged from 90 to 220 min, with a mean estimated blood loss of 3.7 ml. There were no intraoperative complications. Postoperatively, all six patients recovered uneventfully and were discharged home on full feeds after a median of 7 days. On follow-up, the patients had virtually no appreciable scar, were feeding well, stooling, and gaining weight appropriately. The results were similar to those of conventional laparoscopic endorectal pull-through. ConclusionAlthough technically challenging, laparoscopic-assisted endorectal pull-through in infants with Hirschsprung disease can be performed safely through a single umbilical incision with good postoperative results and excellent cosmesis.