Anorectal Malformation Management of Female Patients Part I: Pediatric...
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Podcast
Colorectal Quiz Episode 13: Newborn ARM Part 2
15 min · Published Jun 2021
Video
ARMs in Female Patients: Pediatric Colorectal Controversies 2014
55 min · Published Apr 2012
Video
Surgical Management Of Female Anorectal Malformation Patients Including...
57 min · Published Nov 2018
Video
Laparoscopic Assisted Posterior Sagittal Anorectoplasty
5 min · Published Jan 2025
Podcast
Colorectal Quiz Episode 29: Female ARM-Post Op Management
25 min · Published Mar 2022
Video
Pediatric Colorectal Contraversies Part I: Pediatric Colorectal Contraversies...
Dr. Todd Ponsky · 25 min · Published Aug 2017
Video
Pediatric Surgical Oncology Research Collaborative (PSORC): Studying Rare Pediatric Tumors
56 s · Published May 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Update Course Rewind 2025: Hirschsprung + ARM: Rare but Real
1 min · Published May 2026
Video
Pooling Patients to Study Rare Pediatric Tumors: An Introduction to PSORC
56 s · Published May 2026
Video
The fetal frontier: A review of current and emerging fetal therapies for genetic diseases
44 s · Published May 2026
Video
Indocyanine green assists with sentinel lymph node mapping in pediatric and adolescent patients
1 min · Published May 2026
What the experts said
A perineal fistula opens at or anterior to the fourchette, while a vestibular fistula opens posterior to the hymen in the vestibule.
Don's mobilization goal is to mobilize the rectum just enough to reach the perineal skin with a little bit of tension, not necessarily achieving complete separation from the vagina.
Ivo advocates complete separation of rectum from vagina because incomplete separation may lead to retraction and wound problems, and redo cases often show an undissected plane between rectum and vagina.
Complete rectal mobilization results in loss of some rudimentary internal sphincter tissue.
Michael agrees with more mobilization to bring the rectum down without tension, and warns that dissecting too far from the rectal wall risks entering the posterior vagina even though there is a separate plane (compared to vestibular fistulas with a common wall).
In every redo of a female anorectal malformation, the host finds areolar tissue that had never been dissected by the original surgeon, suggesting inadequate anterior rectal wall mobilization.
The host believes that inadequate anterior rectal wall mobilization creates tension that disrupts the perineal body, leading to reoperations.
Don suggests that many redo cases may have been done in the newborn period without a backup colostomy, which could contribute to complications.
Many female redo cases were done with colostomy under all perfect conditions, but the surgeon did not dissect the anterior wall to the areolar plane.
Common perineal groove is a mucosal-lined channel between vagina and anus, associated with anorectal malformation, where the anus itself is normal in size and position.
Jonathan has not found patients with common perineal groove becoming symptomatic from the groove itself.
The vast majority of common perineal grooves, if observed, will become normal skin over time.
For common perineal grooves that produce mucus and do not resolve, a simple fix is to unroof the mucosa and suture it up.
Common perineal groove is often associated with a perineal fistula.
If a hole must be made during dissection, it is preferable to make it in the vagina rather than the rectum because the vagina heals very well with few complications.
Rectal blood supply is intramural, so injuring the rectal wall hurts its blood supply.
Michael's key technique is to start laterally and find the lateral plane before attempting to separate or create two structures out of the common wall anteriorly.
The lateral plane defines the anterior plane during dissection.
Don's technique is to come in from lateral to anterior, and to start more proximally where the structures are easier to separate, then work from proximal to distal.
The host performs vestibular fistula repair primarily without a colostomy, either in the newborn period or as a repair in the next 3-4 months depending on the child's condition.
The host does not believe these patients need a colostomy in the newborn period followed by repair and then colostomy closure (three stages).
For primary vestibular repair without colostomy, the host waits until the perineal body is healed (around day 6 or 7) before feeding.
The host's practice of delayed feeding is based on experience doing many redo cases, many of which were in patients fed early.
By watching the perineal body carefully during the NPO period, the surgeon can intervene without a dehiscence by taking the patient back to the OR on day 6 or 7 to re-suture the perineal body if needed.
In patients who are fed early and sent home, perineal body disruption may go unnoticed until clinic follow-up at 3-4 weeks or later, or may not be noticed until potty training failure at age 4.
In settings without hyperalimentation, 10% dextrose can be used for NPO periods up to 7 days in healthy, robust children (not in undernourished or very young infants).
Ivo performed a systematic review on perioperative nutrition showing that early enteral nutrition appears better than later nutrition in retrospective studies, similar to findings in adult surgery, but all studies are poor quality.
Kate Deans describes rapid learning healthcare systems as a 10-year-old concept that allows continuous accrual of experience with rapid statistical modeling to provide real-time point-of-care results for rare diseases.
For delayed vestibular repairs (not newborns), the host performs a full GoLYTELY bowel prep until effluent is clear, plus or minus oral antibiotics.
The host's practice for primary vestibular repair includes PICC line placement, hyperalimentation for 7 days, and careful daily inspection of the perineum, with feeding and discharge on day 7 (Tuesday afternoon) if the perineal body is well healed.
About once or twice a year, the host observes early perineal body separation and returns the patient to the OR for reinforcing sutures.
The host does not use a Foley catheter for vestibular or perineal fistula repairs, believing that urine leaking on the perineum is not a big deal.
Jonathan uses a Foley catheter to keep alkaline urine away from the fresh wound.