Posterior Sagittal Anorectoplasty

The location of the intended anoplasty is obvious in males with anorectal malformation, with a discoloration in the area of the sphincteric ellipse

A fistula entering the deltoid or shoulder region of the urethra is classified as a bladder neck fistula

A fistula entering the triceps or humerus area of the urethra is classified as a prostatic fistula

A fistula entering at the elbow of the urethra is classified as a bulbar fistula

Rectal prostatic fistulas and rectal bladder neck fistulas are cases where one could consider whether to perform 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 is amenable to a laparoscopic approach when the rectum is above the PC or puococcygeal line

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

When the rectum is relatively high but reachable through a posterior sagittal approach, placing a catheter in the mucous fistula allows the distal rectum to be inflated through injection so the bulge can be seen and dissected

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

The posterior sagittal incision should incise the center of the sphincter and stay perfectly in the midline

In some cases, removal of the coccyx improves the exposure

The bulge of the distal rectum is facilitated by injection using saline through the mucous fistula

The anterior lip of the rectal lumen is a key anatomic finding

Dissection should be performed within the whitish fascia that envelops the rectum

It is vital to find the plane within the whitish fascia, which allows for the rectum to be mobilized

The lateral dissection 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 during urethral fistula closure

The urethral fistula is closed using long term absorbable suture with a second layer of closure added

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

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