Rectal Atresia - a Unique Anorectal Malformation

Here you see two cases of patients with an anorectal malformation, a male on the left, and a female on the right. What do you notice? I see an anal opening that is too small, but seems to be perfectly located within the sphincteric mechanism, delineated by the pinkish ellipse. This narrow anal opening could represent anal stenosis or rectal atresia. In both cases, one must screen for curino triad and ensure there is no associated presacral mass. Usually it is a teratoma or a meningocele. Here is another example of a case of rectal atresia. The anal canal seems normal, but on careful inspection there is no lumen. This patient presented in a newborn period with abdominal distention, was found to have a normal anal canal, but a probe would not pass, and a colostomy was created. Here is a contrast study done by injection from the anal opening and also through the mucous fistula. It confirms that there is a gap between the upper and lower rectum consistent with rectal atresia, but this gap is quite small. And here is a similar case, but the rectal pouch is much higher. For this case, we began the operation with laparoscopy. And observed a rectum that reached below the peritoneal reflection. In this video, we show a new approach to rectal atresia. We now should treat rectal atresia like Hirschprung's disease. If the rectum is high, we can use laparoscopy to mobilize it. If the rectum is low, as in the case shown here, we can approach it transanal only. This is very different from the approach previously described, which used a posterior sagittal approach to find the distal rectum. With this video, we show that the surgeon can avoid such an incision and reach the rectum transanally just like in a Swenson technique. The patient is prepped and draped sterilely, the anus examined. You see a normal anal canal, and in the third panel with the exposure achieved using the Lone Star retractor that there is no lumen. Here you see the transanal dissection with incision 0.5 centimeters proximal to the dentate line and pull through of the healthy rectum. The mobilized distal rectum is then anastomos to the anal canal, just like in a case for Hirschprung's disease. In this case, the rectal pouch was very low, so we began the operation in prone position. Here I am showing the lumen of what appears to be a normal anal canal, but there is no lumen at all at a depth of about 2 centimeters when I attempt to pass the forceps. You notice that the anal canal is slightly anterior relative to the entire sphincteric ellipse. This is confirmed using the electrical stimulator. We use the Lone Star pins to gain exposure to the anal canal dissection that we have planned. Then we begin by incising the length of the anal sphincter complex. The dissection proceeds looking for the upper rectum, and we are only in the anal area. No incision was used, anterior or posterior to the planned anoplasty. We place silk stitches in what appears to be the rectal lumen, and then open to show the lumen. More silk sutures help with the circumferential dissection. This dissection continues until the rectum is fully mobilized and reaches the intended location for the coloanal anastomosis without any tension. You need to find the typical whitish fascia that surrounds the rectum, just like for all Parps, for a Swenson plane mobilization of the rectum. You note the excellent sphincter muscles outside of this dissection. On the anterior side, you must be careful not to hurt the urethra by staying right against the rectal wall. And now, with the rectum mobilized, we can begin the reconstruction. You will note some vial stitches that were used to imbricate the anterior wall, which was a little thin, due to the dissection close to the urinary tract. The very distal rectum is trimmed off where the fibrotic tissue of the resia was. Full thickness bites are taken from the rectal lumen to the anal canal. Sutures are now placed at 12, 36, and 9 o'clock, which helps take care of any size discrepancy between the two circles, which are being connected to each other. We confirm a good lumen without narrowing and complete the anoplasty and the operation is finished.