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Abstract: Purpose: Restorative proctocolectomy has revolutionized the surgical management of ulcerative colitis and familial polyposis syndromes. Though now evolved to include laparoscopy, this approach has not included alternative pouch designs such as ileal S-pouch reconstruction. This comparative analysis evaluated the combination of laparoscopic-assisted total proctocolectomy with an ileal S-pouch design. Methods: One hundred fifty-six (65 laparoscopic-assisted) total proctocolectomy and ileal S-pouch-anal anastomosis procedures performed between 2003 to 2007 were identified from a prospective surgical database. Operative time, length of incision, length of hospital stay, complications, and return of bowel function were examined. A cost analysis including preoperative through postoperative hospital stay and operating room and postanesthesia care unit costs was performed. Results: The laparoscopic-assisted total proctocolectomy and ileal S-pouch-anal anastomosis procedures were performed for ulcerative colitis in 60 cases and familial adenomatous polyposis in the remaining 5 patients. Four conversions to open technique occurred (6 percent). Comparing laparoscopic and open procedures, the laparoscopic approach took longer to perform than the open technique (mean 451 minutes vs. 347 minutes open; P < 0.001). The mean hospital stay was 6.3 days in the laparoscopic group vs. 8.2 days in the open group (P < 0.001). A detailed cost analysis revealed similar overall costs between the laparoscopic ($18,700) and open approaches ($18,500). Conclusion: Use of a laparoscopic total proctocolectomy with ileal S-pouch-anal anastomosis reconstruction minimizes incision size and shortens hospital stay. At a teaching academic institution, the laparoscopic approach requires longer operative times yet a negligible cost disadvantage.

Abstract: Purpose: Posterior sagittal anorectoplasty is a well accepted procedure utilized for repair of congenital imperforate anus. This procedure allows acceptable function and quality of life in these unfortunate children. However, for obvious reasons it is seldom performed in the adult patient. Methods: In this video, we demonstrate a unique case of a congenital imperforate anus in an adult patient who presented initially with fecal incontinence at 42 years of age. Inspection of her perineum revealed the typical appearance of a congenital imperforate anus with rectovestibular fistula. Intraoperative localization of the external sphincter with a Pena nerve/muscle stimulator (Integra, Plainsboro, NJ) revealed its presence in the appropriate posterior midline location. Results: A two-staged procedure is utilized. This begins with a laparoscopic end sigmoid colostomy followed by the anorectoplasty three weeks later. We demonstrate the technique of posterior sagittal anorectoplasty with the patient in the prone jackknife position. Postoperative function one year after colostomy reversal demonstrates good continence with peak manometric resting and squeeze pressures of 26 mm and 42 mm respectively. Conclusions: Though not usually pertinent in the adult setting, posterior sagittal anorectoplasty should be considered an acceptable option for adults with anorectal malformations.