Posterior Sagittal Anorectoplasty

We present a case of a posterior sagittal anorectoplasty for a low rectal prostatic fistula. Here is a typical perineum of a male with an anorectal malformation. The location of the intended anoplasty is obvious, with a discoloration in the area of the sphincteric ellipse. Remember the schema that we use of determining the location of the distal rectum relative to the urinary tract using a statue's elbow. If the fistula enters the deltoid or shoulder region of the urethra, it is a bladder neck fistula. If it enters the triceps or humerus area, it is a prostatic fistula. And if it enters at the elbow of the urethra, it is a bulbar fistula. Here are representative distal cholostrograms of a recoprostatic fistula on the left and a rectal bladder neck fistula on the right. These are the ones one could consider whether to perform laparoscopy or via a posterior sagittal repair. A properly done distalcholostogram is key to determining the best surgical approach. The image on the top right shows a high rectum with a narrow fistula at the low prostatic level. This is amenable to a laparoscopic approach, as the rectum is above the PC or puococcygeal line. The image on the bottom right shows a lower rectum with a fistula to the bulbar urethra. For this case, a posterior sagittal anorectoplasty is best, and here is the case we are showing in today's video. When the rectum is relatively high but reachable through a posterior sagittal approach, a nice trick is to place a catheter in the mucous fistula so that the distal rectum can be inflated through injection. One can then see the bulge and dissect the distal rectum. The legs are lifted up and the sphincter marked. It is important that the anesthesia team has not given muscle relaxant, as this will interfere with the electrical stimulation. The patient is then placed in prone position. Here you see me palpating the coccyx. We begin the posterior sagittal incision, incising the center of the sphincter and staying perfectly in the midline. And dissect on either side of the coccyx to allow for the wheatlander retractor to be opened widely. In some cases, removal of the coccyx improves further the exposure, as you can see being done here. You now start to see the bulge of the distal rectum. This is facilitated by injection using saline through the mucous fistula. A silk suture is placed into the rectum, and then we dissect out the distal rectum. This releases the rectum from its adherence to the sacrum. The rectum is now opened in the midline. You note that the first stitches were not quite deep enough and only grasped the whitish fascia that surrounds the rectum. Now we can place another silk suture this time into the true rectal lumen and continue placing these silks into the full thickness rectal wall. And now we place a single suture at the rectal urethral fistula location. You can now see the anterior lip of the rectal lumen, a key anatomic finding. And I am placing a probe to show the fistula. I now place stitches across the anterior lip of the rectum. We start dissecting the lateral walls of the rectum. We dissect within the whitish fascia that envelops the rectum. It is vital to find this plane, which allows for the rectum to be mobilized. The lateral dissection defines the anterior dissection. And now we start to come across the anterior wall, lifting the rectum up and dropping the urinary tract down. A mixer right angle clamp is passed to demonstrate the separation of the anteriorectal wall from the fistula, and now the rectum is fully separated from the urinary tract. The rectum is now further mobilized. We take the attachment bands holding the rectum to gain length. If you see fat, you can get closer to the rectal wall. The rectum now easily reaches the perineum to the desired location of the anoplasty, which was previously marked, and now I turn my attention to closing the urethral fistula location. Note how important that initial fistula stitch is for your exposure to this part of the case. The fistula is now closed using long term absorbable suture on the urinary tract. And I have added a second layer of closure. Here you see me marking the posterior edge of the muscle complex, and now I am tacking the posterior edge of the muscle complex to the posterior rectal wall. The wheat lander retractor needs to be relaxed before tying these sutures, and now we place sutures to reconstruct the levators. And here you see me setting up the anoplasty. And now completing the anoplasty with sutures left under a little bit of tension, so that when cut, the anoplasty retracts in slightly. I pass a Hagar to be certain I have not narrowed the lumen. And finally, we close the posterior sagit incision.