ARMs in Male Patients: Pediatric Colorectal Controversies 2014
With Dr. Greg Bates · StayCurrentMD
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Opening the rectum too high during PSARP is safer than opening too low, because opening too low risks entering the urethra
One advantage of laparoscopy is staying on the rectal wall from the beginning, preventing wandering into the urethra
During PSARP, the lateral wall dissection defines the anterior plane and should be performed first, with medial dissection last because that is where the danger lies
If the rectum is not mobilizing easily, you are not in the correct plane; this principle applies to both ARM and Hirschsprung surgery
If you see fat on the rectal wall during dissection, you can get closer to the rectum
Surgeons often stay too lateral thinking they are being safe, when in fact staying right on the rectal wall is safer
In laparoscopic ARM repair, attaching the rectum to presacral fascia with 2-3 permanent sutures prevents prolapse
Leaving too much laxity in the pulled-through rectum contributes to prolapse
During laparoscopic mobilization, only mobilize enough rectum to get it down comfortably with slight tension remaining, rather than extensive mobilization followed by tacking
Mucosal prolapse is not prevented by tacking the rectum and is preferable to stricture because it can be trimmed
When assessing rectal length laparoscopically, desufflate the abdomen before final assessment because insufflation can make the rectum appear shorter than it actually is
Opening the perineum too much during laparoscopic approach weakens the muscle complex; every bit of muscle helps prevent leakage
The 'Gonzalez hernia' (presacral fat that pooches into the midline when fascia is violated) can be mobilized and used as a flap to cover the posterior vagina in recurrent fistula repairs
During anoplasty, aggressively remove distal rectum so it retracts, then use sutures to pull it back down to perineal skin under tension
Over-dissection of the distal rectum leads to excessive looseness and increased prolapse risk; under-dissection leads to stricture
The external skeletal muscle sphincter is probably more important for continence than the internal sphincter embedded in the rectal wall
If a patient has good muscles, good sacrum, good spine, and good repair, they will be continent regardless of whether some internal sphincter tissue was removed
Combining distal colostography with VCUG in the same setting provides complete anatomical information; the colostogram is done first, contrast removed, then VCUG performed
Distal colostography requires both lateral and oblique/AP views with full distention and exact measurements to adequately assess fistula location and rectal length
A properly done distal colostogram is essential to avoid misidentifying the bladder as rectum during PSARP, which can occur because the bladder can appear midline, white, and rectum-like
Passing a flexible neonatal scope through the mucous fistula allows visualization of light transmission to confirm rectal location during PSARP
Bladder-neck fistulas typically enter at right angles and narrow down, making them easier to define and ideal for laparoscopic approach
If uncertain about fistula location during laparoscopic dissection, opening the rectum allows identification of the fistula from inside
The fistula typically narrows down significantly, and the correct level to divide it is where this narrowing occurs
For laparoscopic fistula ligation, preload a Maryland dissector through an endo-loop, divide the fistula, then slide the loop over the Maryland for controlled ligation
Metal clips for fistula closure tend to erode into the urethra; endo-loop ligation is preferred
When ligating the fistula, the stick (Maryland) should be placed distally with the loop trailing behind for better control; placing the loop distally is harder to control
Bladder-neck fistulas are distinguished from prostatic fistulas by location above the angle of the urethra; prostatic fistulas are at or below the urethral angle
Cystoscopy by an experienced urologist can identify the fistula in approximately 9 out of 10 cases, though prior surgical experience found only 3 out of 10 fistulas visible cystoscopically
Bulbar fistulas are often not visible on cystoscopy due to the tiny size of the opening
A fistula at the urethral elbow or below is classified as bulbar; above the elbow is prostatic; at the bladder neck is bladder-neck
Two critical characteristics from colostography are: exact fistula location and how low/bulbous the rectum is, which determines surgical approach feasibility
A very low bulbar fistula can be missed if the surgeon performs anoplasty without addressing the fistula, resulting in a patient who urinates through the anus (persistent fistula)
Fistulas at the same level can have very different rectal anatomy (bulbous vs. tapered), which determines whether PSARP or laparoscopy is more appropriate
In ARM, the IMA cannot be taken because prior colostomy has divided marginal vessels; taking the IMA will allow the rectum to reach but leave it without blood supply
ARM rectal mobilization depends on IMA branches and intramural blood supply in the rectal wall, requiring intimate wall dissection unlike Hirschsprung where the IMA can be safely divided
A Heineke-Mikulicz plasty (cutting horizontally and suturing vertically) on a bulbous rectum can gain 2-3 additional centimeters of length while addressing dilation
When mobilizing the rectum, use bulldogs on vessels to test which can be divided without compromising blood supply before making permanent divisions
A properly placed newborn colostomy (as proximal in the sigmoid as possible) prevents the need for colostomy takedown during definitive repair
If the mucous fistula must be taken down to gain length, perform a colocolonic anastomosis at the time of repair rather than leaving a difficult Hartmann closure behind the bladder for later
To assess adequate rectal length, the rectum should reach 2 finger-breadths (4 cm) below the pubic bone; marking this point on the perineum predicts successful pull-through
For rectal atresia or stenosis, split the distal 360-degree anus into 180 degrees, then anastomose the mobilized proximal rectum (unfolded from circle to hemicircle) to preserve the dentate line without dissection
The PSARP approach, first utilized in 1980 by Dr. Peña, revolutionized pelvic surgery including anorectal malformations
The fundamental principles of ARM repair are: identify where the rectum ends, ligate the distal fistula without injuring other structures, mobilize the rectum to comfortably reach the perineum, and place it in the center of the sphincter