How I Do It Levitt PSARP

A no-fistula anorectal malformation defect is managed very similarly to a bulbar urethral fistula.

The key to starting any anorectal malformation repair is a good imaging study.

Fistula levels can be classified anatomically: bladder neck fistula is at the deltoid level (C), rectoprostatic fistula is at the triceps level (B), and rectobulbar fistula is at the elbow of the urethral curve or distal (A).

It is important to mark the sphincter location before making the posterior sagittal incision because once the incision is made, it is hard to know exactly where the sphincter center is.

The sphincters must be cut perfectly in the midline so that they can be easily reconstructed.

Without a good distal colostogram, the midline whitish structure at the center of the dissection could be the urinary tract rather than the rectum.

Lateral dissection should be performed before turning attention anteriorly during rectal mobilization.

The initial anterior dissection to separate rectum from urinary tract is a submucosal dissection for the first few millimeters.

During lateral dissection, any fat seen means you can get closer to the rectum safely.

The lower the rectum is positioned, the longer is the common wall between rectum and urinary tract.

A lower rectum is easier to repair in one sense but harder because there is a longer dissection adjacent to the urethra.

A rectum at the bulbar level is too low to approach laparoscopically and is much safer to approach posterior sagittally.

Approaching a low rectum laparoscopically risks leaving behind distal rectum, a remnant of the urethral fistula, or a roof.

The rectum must be in the correct dissection plane or it will not mobilize properly.

When closing the muscle complex, taking a bite of the rectum helps to avoid prolapse.

The rectum should lie adjacent to, not constricted by, the muscle complex.

As much rectum as possible should be preserved during the repair.

The anoplasty is performed with 16 sutures under slight tension so that when stitches are cut, the rectum will gently retract and appear like a normal anus.

Dilations begin at 2 weeks postoperatively.

Colostomy closure can take place 2 to 3 months after PSARP once the anus has reached its desired size.