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Journal of Indian Association of Pediatric Surgeons
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BRIEF REPORT
Year : 2021  |  Volume : 26  |  Issue : 5  |  Page : 334-335
 

Abdominoperineal tunnel crafted with alken's telescopic dilators: A novel technique!


Department of Pediatric Surgery, Park Clinic, Kolkata, West Bengal, India

Date of Submission09-Jun-2020
Date of Decision23-Jul-2020
Date of Acceptance04-Aug-2020
Date of Web Publication16-Sep-2021

Correspondence Address:
Dr. Uday Sankar Chatterjee
Park Clinic, 4, Gorky Terrace, Kolkata - 700 017, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.JIAPS_129_20

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   Abstract 


Background: Abdomino-perineal pull through procedure needs perineal dissection and for that swap of supine to prone may be necessary. To avoid that as well as to avoid neuro-muscular damage; we are describing a simple minimal invasive procedure with help of Alken's telescopic dilators.
Patients & Methods: We created abdomino-perineal tunnel with Alken's telescopic dilators to bring down the lumen of intestine in perineum in eight patients.
Results: Operative time happened to be less and procedure found to be less traumatic. All the eight patients had satisfactory outcome
Conclusions: Actually, we have repurposed the Alken's dilator for creation of abdomino-perineal tunnel or track to get benefit of minimal dissection of perineum during pull-through procedure as well as to avoid neuro-muscular damage.


Keywords: Alken's dilator, Amplatz sheath, anorectal malformation, neovagina, pull through


How to cite this article:
Chatterjee US, Basu AK, Das S, Mitra D. Abdominoperineal tunnel crafted with alken's telescopic dilators: A novel technique!. J Indian Assoc Pediatr Surg 2021;26:334-5

How to cite this URL:
Chatterjee US, Basu AK, Das S, Mitra D. Abdominoperineal tunnel crafted with alken's telescopic dilators: A novel technique!. J Indian Assoc Pediatr Surg [serial online] 2021 [cited 2022 Jul 6];26:334-5. Available from: https://www.jiaps.com/text.asp?2021/26/5/334/326054





   Introduction Top


Abdominoperineal pull-through procedure needs perineal dissection to create a tunnel or track through perineal muscle complex to bring down intestine in patients with high anorectal malformation (ARM) or in other anomalies. Construction of abdominoperineal tunnel demands scrupulousness in dissection to avoid neuromuscular damage.[1] Not only that, the change of position from prone to supine may be necessary and sometimes that may not be comfortable for anesthetists as well as for surgeons.

We describe a simple minimally invasive procedure to create that perineal tunnel with Alken's telescopic dilator[2] in the supine position.


   Patients and Methods Top


Five patients of high ARM, two patients of ileal pull-through for the reconstruction of vaginal substitute, and one patient of cloacal exstrophy, with the age ranged from 7 months to 8 years, were operated. We did laparotomy in “frog position” and dissected out the necessary intestinal segment to be pulled down in the perineum. Following that, a small incision was made in the perineum to identify perineal muscle complex and to pass the initial puncture needle, through the center of perineal muscle complex into retrovesical space under visual guidance from the abdominal cavity. Needle was then loaded with guide wire that guided a hollow guide rod to pass into the abdomen. Following that, a set of tubular, concentric, Alken's telescopic dilators of gradually increasing sizes [Figure 1]a was threaded on that guide rod for dilation [Figure 1]b. At completion of dilation with Alken's dilators, Amplatz sheath was placed in the perineo-abdominal tunnel [Figure 2] through which segment of gut was pulled in the perineum [Figure 3].
Figure 1: Alken's dilators (a) and dilation (b)

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Figure 2: Dilation with Alken's dilators and Amplatz sheath

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Figure 3: Amplatz sheath in abdominoperineal tunnel in cloacal exstrophy

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   Results Top


All the eight patients had good wound healing. Two patients with ileal vagina complained of occasional foul smelling mucous discharge in follow-up. They were advised and demonstrated regular saline irrigation and that helped. Continence score of all four patients out of five was around 5 as per the Kelly's score,[3] and one patient with partial sacral agenesis not only needed regular anal dilation for few months but also needed clean intermittent catheterization for incomplete void.


   Discussion Top


Alken's telescopic dilator[2] is innovated to create percutaneous track to access the renal pelvicalyceal system for the removal of renal calculus, i.e., percutaneous nephrolithotripsy. We have repurposed of Alken's dilator for the creation of abdomin-operineal tunnel or track to get the benefit of minimal dissection of the perineum during pull-through procedure [Video 1] as well as to avoid neuromuscular damage. However, we cannot claim less significant damage of the perineal tissues with this procedure as the sample size of this study is small and not controlled with necessary matched group. Laparoscopic pull through[4],[5],[6] would be truly minimal invasive if this described procedure is coupled together as an adjunct.





   Conclusions Top


This procedure was done without changing posture and with minimal injuries to surrounding perineal tissues, due to its minimal invasion in the perineum and around retrovesical space. This minimally invasive procedure also saved total operative time.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Peña A. Posterior sagittal anorectoplasty as a secondary operation for the treatment of fecal incontinence. J Pediatr Surg 1983;18:762-73.  Back to cited text no. 1
    
2.
Alken P. The telescope dilators. World J Urol 1985;3:7-10.  Back to cited text no. 2
    
3.
Bhatnagar V. Assessment of postoperative results in anorectal malformations. J Indian Assoc Pediatr Surg 2005;10:80-5.  Back to cited text no. 3
  [Full text]  
4.
Raghupathy RK, Moorthy PK, Rajamani G, Kumaran V, Diraviaraj R, Mohan NV, et al. Laparoscopically assisted anorectoplasty for high ARM. J Indian Assoc Pediatr Surg 2003;8:202 7.   Back to cited text no. 4
    
5.
Yamataka A, Segawa O, Yoshida R, Kobayashi H, Kameoka S, Miyano T. Laparoscopic muscle electro stimulation during laparoscopy assisted anorectal pull through for high imperforate anus. J Pediatr Surg 2001;36:1659 61.  Back to cited text no. 5
    
6.
Georgeson KE, Inge TH, Albanese CT. Laparoscopically assisted anorectal pull-through for high imperforate anus--A new technique. J Pediatr Surg 2000;35:927-30.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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    Abstract
   Introduction
   Patients and Methods
   Results
   Discussion
   Conclusions
    References
    Article Figures

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