The Perineal Body Preserving PSARP (PPP)

The patient is a female infant born with an anorectal malformation and a rectovesibular fistula.

Examination reveals a normal introitus with the rectum ending as a fistula in the vestibule and a pink sphincteric ellipse.

For females with anorectal malformation, anatomic options include rectovesibular fistula, rectocloacal fistula, rectoperitoneal fistula in the center of the perineal body, rectoperitoneal fistula within the sphincteric complex at its anteriormost extent, anal stenosis, and slightly anteriorly located but otherwise normal anus.

With all anorectal malformations, it is vital to inspect for any associated anomalies.

In females with anorectal malformation, vaginoscopy is performed to look for associated Mullerian anomalies such as vaginal septum, distal vaginal atresia, and uterine anomalies.

In this case, vaginoscopy showed a normal vagina and a single cervix.

The traditional PSARP is done in prone position with cutting of the perineal body down to the vestibular fistula, including a long posterior sagittal incision from the coccyx, mobilizing the rectum off the posterior vaginal wall, repairing the perineal body, completing the anoplasty, and closing the posterior sagittal incision.

The perineal body preserving technique (PPP) is an alternative to traditional PSARP.

An electrical stimulator (the same one used by anesthesia for train of four) can define the extent of the sphincter complex.

For the electrical stimulator to work well, muscle relaxation must be avoided.

In the PPP technique, the entire incision need only be the extent of the sphincter; no posterior and no anterior incision is needed.

Care must be taken that retractors do not split the perineal body inadvertently.

A suture is placed at the anteriormost extent of the intended anoplasty to help avoid inadvertent splitting of the perineal body.

In the PPP, the perineal body is not incised.

The lateral aspects of the rectum are intimately attached to the vaginal wall and must be dissected with great care to avoid injury.

A helpful concept is to think of the PPP like a bulbar fistula repair in a male with anorectal malformation.

A stitch is placed in the fistula, analogous to the approach for a bulbar fistula.

Placement of multiple sutures across the anterior lip of the rectal wall is a vitally important step because it facilitates lifting of the rectal wall and separation from the posterior vaginal wall.

The rectum is mobilized and dissected within the whitish fascia that envelops it.

A Hagar dilator in the vagina facilitates dissection of the rectum from the vagina.

The stitch on the fistula is passed into the introitus and the fistula tissue is managed at the end of the case.

The perineal body muscles are sutured together where the fistula used to be, forming the sphincter anterior to the new anoplasty.

The anoplasty is placed within the initial incision, which is the center of the sphincters.

In the PPP technique, no sutures are needed in the perineal body's skin; the perineal body skin is untouched.

The rectum is split on its anterior and posterior wall.

The anoplasty is completed with 16 absorbable sutures placed full thickness, rectal wall to anal skin.

After completion of the anoplasty, the patient is turned supine and the introitus is exposed.

The fistula tissue is excised and the mucosa of the vestibule is repaired where the fistula had been.