Abdominoperineal Tunnel Crafted with Alken's Telescopic Dilators: A Novel Technique!

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. Copyright:

INTRODUCTION

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

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 1a] was threaded on that guide rod for dilation [Figure 1b]. 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)

Figure 2

Dilation with Alken's dilators and Amplatz sheath

Figure 3

Amplatz sheath in abdominoperineal tunnel in cloacal exstrophy

RESULTS

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

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[456] would be truly minimal invasive if this described procedure is coupled together as an adjunct.

CONCLUSIONS

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.