Posterior Sagittal Anorectoplasty

The location of the intended anoplasty in a male with anorectal malformation is marked by discoloration in the area of the sphincteric ellipse.

A "statue's elbow" schema is used to determine the location of the distal rectum relative to the urinary tract: fistula entering the deltoid/shoulder region is bladder neck, triceps/humerus area is prostatic, and elbow of the urethra is bulbar.

Recto-prostatic and rectal bladder neck fistulas are the types one could consider for either laparoscopy or posterior sagittal repair.

A properly done distal colostogram is key to determining the best surgical approach.

A high rectum with a narrow fistula at the low prostatic level, where the rectum is above the puborectalis (PC) line, is amenable to a laparoscopic approach.

A lower rectum with a fistula to the bulbar urethra is best treated with posterior sagittal anorectoplasty.

When the rectum is relatively high but reachable through a posterior sagittal approach, placing a catheter in the mucous fistula to inflate the distal rectum allows visualization of the bulge and facilitates dissection.

It is important that the anesthesia team has not given muscle relaxant, as this will interfere with electrical stimulation used to mark the sphincter.

The posterior sagittal incision is made through the center of the sphincter, staying perfectly in the midline.

In some cases, removal of the coccyx improves exposure during posterior sagittal anorectoplasty.

Injection of saline through the mucous fistula facilitates visualization of the distal rectum bulge.

The anterior lip of the rectal lumen is a key anatomic finding during posterior sagittal anorectoplasty.

Dissection within the whitish fascia that envelops the rectum is vital to find the correct plane that allows for rectal mobilization.

The lateral dissection of the rectum defines the anterior dissection.

If you see fat during rectal mobilization, you can get closer to the rectal wall.

The initial fistula stitch is important for exposure when closing the urethral fistula.

The urethral fistula is closed using long-term absorbable suture in two layers.

The Wheatlander retractor needs to be relaxed before tying sutures that tack the posterior edge of the muscle complex to the posterior rectal wall.

Anoplasty sutures are left under a little bit of tension so that when cut, the anoplasty retracts in slightly.

A Hagar dilator is passed at the end of the procedure to ensure the anoplasty lumen has not been narrowed.