SciELO - Scientific Electronic Library Online

vol.49 issue1A survey on the current status of laparoscopic training in paediatric surgery in South AfricaLaparoscopically inserted button colostomy as a venting stoma and access port for the administration of antegrade enemas in African degenerative leiomyopathy author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand



Related links

  • On index processCited by Google
  • On index processSimilars in Google


South African Journal of Surgery

On-line version ISSN 2078-5151
Print version ISSN 0038-2361

S. Afr. j. surg. vol.49 n.1 Cape Town Feb. 2011




A comparison of laparoscopic-assisted (LAARP) and posterior sagittal (PSARP) anorectoplasty in the outcome of intermediate and high anorectal malformations



C. de VosI; M. ArnoldII; D. SidlerIII; S. W. MooreIV

IM.B. CH.B., D.M.O.; Division of Paediatric Surgery, Stellenbosch University, Tygerberg, W Cape
IIM.B. CH.B., D.CH.; Division of Paediatric Surgery, Stellenbosch University, Tygerberg, W Cape
IIIM.D. (berne), M.Phil. (applied Ethics), F.C.S. (SA)Division of Paediatric Surgery, Stellenbosch University, Tygerberg, W Cape
IVM.B. Ch.B., F.R.C.S. (ed.), M.D.Division of Paediatric Surgery, Stellenbosch University, Tygerberg, W Cape




INTRODUCTION: Laparoscopic-assisted anorectoplasty (LAARP) has gained popularity since its introduction in 2000. Further evidence is needed to compare its outcome with the gold standard of posterior sagittal anorectoplasty (PSARP).
METHOD: A retrospective review of patients presenting with anorectal malformation (ARM) in the period 2000 - 2009. Demographics, associated abnormalities, and operative and post-operative complications were assessed. The functional outcome in children older than 3 years was assessed, applying the Krickenbeck scoring system and, where possible, by interviewing parents. Patients with cloacal abnormalities were excluded. Patients with a LAARP were compared with those managed by PSARP.
RESULTS: Seventy-three patients with ARM were identified during the study period. Male to female ratio was 1.6:1. All 32 low ARMs (perineal and vestibular fistulae) were excluded. Thirty-nine had levator or supra-levator lesions. Twenty males presented with recto-bulbar, 3 with recto-prostatic, and 1 with a recto-vesical fistula; 2 had no fistula; and in 2 the data were insufficient to determine the level. Among the females, 6 had recto-vaginal fistulae, 4 had cloacas and 1 had an ARM without fistula. There were 3 syndromic ARMs (2 trisomy 21 and 1 Baller-Gerold syndrome). One neonate with a long-gap oesophageal atresia had a successful primary LAARP. Seventy-five per cent of all patients had VACTERL associations. Two early deaths after colostomy formation were related to a cardiac anomaly and an oesophageal atresia.
In both groups, mean age at anoplasty was 8 months. Twenty of the intermediate/high lesions were treated with LAARP, and 19 by PSARP.
There were slightly more complications in the LAARP group; intra-operative injury to the vas deferens and urethra occurred once each. Post-operatively, 2 port-site hernias and 1 case of pelvic sepsis occurred. A poorly sited colostomy caused difficulty in 2 patients. Two patients were converted to laparotomy: severe adhesions in one and a poorly sited stoma in another. Five patients required redo-anoplasty for mucosal prolapse, anal stenosis, incorrect placement of the anus, retraction of the rectum and an ischaemic rectal stricture. Complications in the PSARP group included 2 wound dehiscences, 1 anal stenosis, 3 mucosal prolapses, 1 recurrent fistula and 2 incorrect anal placements requiring redo surgery.
The Krickenbeck questionnaire was used in 70% of PSARPs (mean age 5.9 years) and LAARPs (mean age 5.5 years) for a functional assessment. Both groups showed voluntary bowel movements in 14%. Soiling and overflow incontinence was a significant problem. Grade III constipation was less common in the LAARP (14%) than PSARP (21%) group. Four patients in the LAARP group were reliant on regular rectal washouts compared with 6 in the PSARP group.
CONCLUSION: Both LAARP and PSARP can successfully treat ARM but have specific associated problems.


“Full text available only in PDF format”



1. Levitt MA, Pena A. Anorectal malformations. Orphanet J Rare Dis 2007;2:33.         [ Links ]

2. Holschneider A, Hutson J, Pena A, et al. Preliminary report on the International Conference for the Development of Standards for the Treatment of Anorectal Malformations. J Pediatr Surg 2005;40(10):1521-1526.         [ Links ]

3. Rintala RJ, Pakarinen MP. Imperforate anus: long- and short-term outcome. Semin Pediatr Surg 2008;17(2):79-89.         [ Links ]

4. Hashish MS, Dawoud HH, Hirschl RB, et al. Long-term functional outcome and quality of life in patients with high imperforate anus. J Pediatr Surg 2010145(1):224-230.         [ Links ]

5. Ashcraft K. Nonurologic anomalies associated with anorectal malformations. In: Anorectal Malformations in Children. Holschneider AM, Hutson JM, eds. Berlin: Springer-Verlag, 2006:263-269.         [ Links ]

6. Stephens FD. Wingspread anomalies, rarities, and super rarities of the anorectum and cloaca. Birth Defects Orig Artic Ser 1988;24(4):581-585.         [ Links ]

7. deVries PA, Pena A. Posterior sagittal anorectoplasty. J Pediatr Surg 1982;117(5):638-643.         [ Links ]

8. Georgeson K. Laparoscopic-assisted anorectal pull-through. Semin Pediatr Surg 2007;16(4):266-269.         [ Links ]

9. Georgeson KE, Inge TH, Albanese CT. Laparoscopically assisted anorectal pull-through for high imperforate anus - a new technique. J Pediatr Surg 2000135(6):927-930; discussion 30-1.         [ Links ]

10. Hay SA. Transperineal rectovesical fistula ligation in laparoscopic-assisted abdominoperineal pull-through for high anorectal malformations. J Laparoendosc Adv Surg Tech A 2009;19 Suppl 1:S77-79.         [ Links ]

11. Lopez M, Kalfa N, Allal H, et al. Anorectal malformation (ARM) with bladder fistula: Advantages of a laparoscopic approach. Eur J Pediatr Surg 2009; Jun 10 [epub ahead of print].         [ Links ]

12. Al-Hozaim O, Al-Maary J, AlQahtani A, Zamakhshary M. Laparoscopic-assisted anorectal pull-through for anorectal malformations: a systematic review and the need for standardization of outcome reporting. J Pediatr Surg 2010;45(7):1500-1504.         [ Links ]

13. Pena A. Continence after posterior sagittal anorectoplasty. J Pediatr Surg 1992;27(3):415-417.         [ Links ]

14. Rintala RJ, Lindahl H. Is normal bowel function possible after repair of intermediate and high anorectal malformations? J Pediatr Surg 1995;30(3):491-494.         [ Links ]

15. Hassett S, Snell S, Hughes-Thomas A, Holmes K. 10-year outcome of children born with anorectal malformation, treated by posterior sagittal anorectoplasty, assessed according to the Krickenbeck classification. J Pediatr Surg 2009;44(2):399-403.         [ Links ]

16. Yang J, Zhang W, Feng J, et al. Comparison of clinical outcomes and anorectal manometry in patients with congenital anorectal malformations treated with posterior sagittal anorectoplasty and laparoscopically assisted anorectal pull through. J Pediatr Surg 2009;44(12):2380-2383.         [ Links ]

17. Kuwabara K, Matsuda S, Fushimi K, Ishikawa KB, Horiguchi H, Fujimori K. Community-based appraisal of laparoscopic abdominal surgery in Japan. J Surg Res 2010; epub Oct 21.         [ Links ]

18. Norwood MG, Stephens JH, Hewett PJ. The nursing and financial implications of laparoscopic colorectal surgery: data from a randomised controlled trial. Colorectal Dis 2010; Oct 19 [epub ahead of print].         [ Links ]

19. Mattix KD, Novotny NM, Shelley AA, Rescorla FJ. Malone antegrade continence enema (MACE) for fecal incontinence in imperforate anus improves quality of life. Pediatr Surg Int 2007;23(12):1175-1177.         [ Links ]

20. Al-Malki TA. Medical and surgical management of fecal incontinence after repair of high imperforate anus anomalies. Saudi Med J 2010;31(3):284-288.         [ Links ]

Creative Commons License All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License