PSARP was the standard of care since 1982 for the management of anorectal malformations, especially the high types. Georgeson reported the laparoscopic approach (LAARP) with promising results in the year 2000 [3]. The latter approach has spread globally with a relative lack of outcome data. Comparing the outcome results of the two approaches may add more evidence to support its utilization.
Although we could not demonstrate any significant differences between the use of LAARP or PSARP, regarding the three categories of the Modified Clinical scoring for defecation function, the overall trend would appear that more patients who underwent LAARP had a better functional outcome. Moreover, the fact that both were comparable may support the minimal approach (LAARP) associated with less stress on patients, better cosmesis, faster recovery, and shorter hospital stay.
In the literature, different scoring systems (subjective and objective) were used to assess continent, rectal tone, soiling, and bowel motion [5,6,7,8,9,10]. We have modified the clinical score for the defecation function of the Japanese study group of anorectal anomalies to show clear outcome data and simplify reporting by patients and families.
A systemic review by Al-Hozaim et al. in 2009 showed that only four studies compared the outcome between LAARP and PSARP [11]. The total numbers of patients were 47; they compared the following: stool frequency, continence, the anatomic position of pull through, and sphincter function. All of them concluded that LAARP seems to be superior for patients with high type anorectal malformation, with a long-term follow-up is needed to assess fecal continence [5,6,7,8]. Also, a similar conclusion was found in a systematic review by Shawyer AC [12] and a meta-analysis by Han Y [13].
Wong and colleagues used magnetic resonance (MRI) to assess the anatomical features after LAARP and compared functional outcomes with historical controls who had PSARP. MRI of the pelvis was performed postoperatively, and a semi-quantitative score was used to assess the degree of sphincter symmetry, peri-rectal fibrosis, and the position of the pull-through rectum. The defecation status of these patients was also recorded. The study concluded that LAARP allows for more optimal anatomical reconstruction in patients with high/intermediate types of the imperforated anus [7].
An-Xiao Ming et al. reviewed 32 patients who underwent LAARP and compared them with 34 patients who underwent PSARP using Krickenbeck classification and reported that the long-term functional outcomes after LAARP were equivalent if not better than those of PSARP [14].
Ichijo et al. compared both types of surgery objectively using anal endosonography and pelvic magnetic resonance imaging to assess the pelvic muscle thickening, and he concluded that there is no statistically significant difference. Subjectively, he used “Continence evaluation questionnaire score” which includes frequency of defecation, soiling, perianal erosion, anal shape and medication, and he concluded that the score was generally higher after laparoscopic surgery throughout the study, but it was only statistically significant at 3 and 4 years of age [5].
Using the Kelly scoring system, one study showed equivalent results [8], while others have shown the superiority of LAARP over PSARP [15, 16].
In terms of long-term complications, the incidence of anal stenosis was higher in the posterior sagittal approach, as shown by our data and others [14]. This may be explained by the effect of open dissection. On the other hand, rectal prolapse was more in laparoscopy technique, although it did not reach significance. This has been reported previously [14, 17]. Other studies did not find such this effect [18]. We believe that the extensive reconstruction in the PSARP approach induces more fibrosis, hence fixing the anorectum to the pelvis structures and preventing rectal prolapse.
In ARM with rectourethral fistulae, there is no accurate guidance (landmark) to where to stop dissection of the fistula, fearing injury to the urethra. Getting close to the urethra could result in urethral stricture, and dividing away from it may result in a urethral diverticulum. We have encountered early in the series two stenoses (managed with dilatation successfully) and two urethral diverticula with no significant problems. All were in the LAARP.
Koga and his colleagues invented the intraoperative measurement of the rectourethral fistula using a cystoscope with a calibrated catheter to overcome the dilemma [19].
The differences in operative time between the two approaches vary among the studies in the literature; some of them reported shorter operative time in the laparoscopic pull through [7, 9], whereas Koga H reported the opposite [20].
The postoperative hospital stay in the LAARP group was significantly shorter, which is supported by many studies as well [7, 9, 15].
In conclusion, the defecation function and complication rate for both laparoscopic and open groups were almost similar from the statistical point of view. There was some trending in favor of the laparoscopic approach regarding shorter operative time, shorter hospital stay and less stenoses; the latter and the minimal nature of the laparoscopic approach may justify its utilization over the open one. Long-term follow-up with larger sample size studies may be needed to elicit the differences between the two approaches.
