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How I Do It Levitt PSARP

Video Published 2018-10-19 Updated 2026-08-01

Timestops (4)

Procedure Overview and Patient Positioning

Posterior Sagittal Incision and Rectal Identification

Rectal Mobilization and Dissection Technique

Levator Repair and Anoplasty Closure

Topic Overview

Dr. Mark Levitt from Nationwide Children's Hospital demonstrates the posterior sagittal anorectoplasty (PSARP) technique for anorectal malformations, specifically focusing on no-fistula and bulbar fistula defects. The presentation covers preoperative imaging requirements, patient positioning, the critical midline dissection through sphincter muscles, safe separation of rectum from urinary tract, and reconstruction including levator and muscle complex closure. Key technical points include the importance of accurate preoperative distal colostography to distinguish rectum from urinary tract, the submucosal anterior dissection technique to avoid urethral injury, and the rationale against laparoscopic approaches for low rectal defects due to risk of leaving distal rectal remnants.

Key Takeaways

Preoperative distal colostography is essential to distinguish rectum from urinary tract during midline dissection. (0:45)
Anterior dissection begins submucosally for first few millimeters; lateral dissection defines safe anterior plane. (3:35)
Laparoscopic approach to rectobulbar fistulas risks leaving distal rectal remnants; PSARP is safer for low defects. (4:38)
Muscle complex closure should include rectal bites to prevent prolapse; rectum should lie adjacent, not constricted. (5:44)
Anoplasty uses 16 sutures under slight tension; dilations start at 2 weeks, colostomy closure at 2-3 months. (6:32)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — host
Mark Levitt — guest

Chapters

0:00Introduction and Preoperative Imaging — Introduction to the PSARP technique for no-fistula and bulbar fistula defects, with emphasis on the critical importance of quality preoperative distal colostography and classification of fistula levels.
1:31Patient Positioning and Initial Incision — Patient positioning in prone with proper cushioning, identification and marking of the sphincter ellipse, and initiation of the midline posterior sagittal incision through parasagittal fibers and sphincter muscles.
2:34Rectal Dissection and Urethral Separation — Identification of the midline rectal structure, placement of traction sutures, lateral and anterior dissection technique to safely separate rectum from urinary tract using submucosal plane, and mobilization to gain rectal length.
4:51Reconstruction and Anoplasty — Closure of the area adjacent to urinary tract, levator and muscle complex reconstruction with rectal incorporation to prevent prolapse, posterior sagittal incision repair, and creation of the anoplasty under slight tension with postoperative dilation plan.

Key claims

0:20A no fistula defect is very similar to a bulbar fistula in terms of surgical approach — Mark Levitt
0:45The key to starting any anorectal malformation case is a good imaging study — Mark Levitt
1:05A bladder neck fistula is at the deltoid level, rectoprostatic fistula at the triceps level, and rectobulbar fistula at the elbow of the urethral curve or distal — Mark Levitt
1:31Patient positioning requires prone position with buttocks elevated, good axillary support, and feet supported so toes don't touch the bed — Mark Levitt
1:50The sphincter ellipse should be marked before the posterior sagittal incision because it becomes hard to identify afterward — Mark Levitt
2:28The sphincters must be cut perfectly in the midline so they can be easily reconstructed — Mark Levitt
2:42Without a good distal colostogram, the midline whitish structure could be urinary tract rather than rectum — Mark Levitt
3:09The anterior dissection should continue until running out of rectum, which is the point where a fistula would normally be — Mark Levitt
3:21Lateral dissection should be performed before turning attention anteriorly — Mark Levitt
3:35The initial anterior dissection for the first few millimeters is a submucosal dissection — Mark Levitt
4:07The lateral dissection defines the anterior dissection; when unsure, go lateral — Mark Levitt
4:14When lateral, any fat seen means you can get closer to the rectum — Mark Levitt
4:23The lower the rectum, the longer the common wall between rectum and urinary tract — Mark Levitt
4:29Lower rectum is easier in that it is lower, but harder because there is a longer dissection adjacent to the urethra — Mark Levitt
4:38A rectobulbar fistula is too low to approach laparoscopically and is much safer to approach posterior sagittally — Mark Levitt
4:51Laparoscopic approach to low rectum risks leaving behind distal rectum, a remnant of the urethral fistula, or a roof — Mark Levitt
5:13If you see fat during dissection, you can get closer to the rectum — Mark Levitt
5:16You must be in the correct plane for the rectum to mobilize — Mark Levitt
5:44For muscle complex bites, taking a bite of the rectum helps to avoid prolapse — Mark Levitt
5:54The rectum should lie adjacent to, not constricted by, the muscle complex — Mark Levitt
6:15Very little rectum should be trimmed; preserve as much rectum as possible — Mark Levitt
6:32The anoplasty uses 16 sutures — Mark Levitt
6:36The anoplasty should be under slight tension so that when stitches are cut, the rectum will gently retract in — Mark Levitt
6:52Dilations will begin at 2 weeks postoperatively — Mark Levitt
6:52Colostomy closure can take place 2 to 3 months after surgery once the anus has reached its desired size — Mark Levitt

Cases discussed

0:20Demonstration case of posterior sagittal anorectoplasty for a no-fistula anorectal malformation defect

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Posterior Sagittal Anorectoplasty: Plane, Position, and Precision

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Foundation: Imaging Defines the Operation

Know the fistula level before you cut. "Obviously the key to starting any such case is a good imaging study" 0:45. The distal colostogram tells you whether you're separating rectum from bladder neck (deltoid level), prostate (triceps level), or bulbar urethra (elbow or distal) 1:05. Without that study, the midline whitish structure you encounter could be urinary tract rather than rectum 2:42. The level determines not just difficulty but approach: a rectobulbar fistula is too low to approach laparoscopically and is much safer posterior sagittally 4:38. Attempting laparoscopy on low rectum risks leaving behind distal rectum, a fistula remnant, or a urethral roof 4:51.

Setup: Mark What You Cannot Reconstruct Blind

Identify the sphincter ellipse before making the incision. The sphincter becomes hard to identify once the posterior sagittal incision is made 1:50. Mark it in prone position with buttocks elevated, good axillary support, and feet supported so toes don't touch the bed 1:31. Then cut the sphincters perfectly in the midline so they can be easily reconstructed 2:28. A millimeter off-center compounds through the entire repair.

Dissection Strategy: Lateral Defines Anterior

When uncertain about the anterior plane, return to lateral dissection. The lateral dissection should be performed before turning attention anteriorly 3:21, and "the lateral defines the anterior. If you're not sure, go lateral" 4:07. When you're lateral, any fat you see means you can get closer to the rectum 4:14 5:13. The anterior dissection begins as a submucosal plane for the first few millimeters 3:35, separating rectum from urinary tract below. Continue anteriorly until you run out of rectum — that's where a fistula would normally be 3:09.

The lower the rectum, the longer the common wall. Lower rectum is easier in that it sits lower, but harder because there is a longer dissection adjacent to the urethra 4:23 4:29. You must be in the correct plane for the rectum to mobilize 5:16. If it doesn't come, you're not where you think you are.

Reconstruction: Adjacency Without Constriction

Take a bite of rectum with the muscle complex sutures to prevent prolapse 5:44, but position those sutures so the rectum lies adjacent to, not constricted by, the muscle complex 5:54. This is the difference between a functional repair and one that obstructs. Trim very little rectum — preserve as much as possible 6:15. The anoplasty uses 16 sutures 6:32 placed under slight tension so that when the stitches are cut, the rectum gently retracts inward 6:36.

Postoperative Course: Time to Tissue Maturation

Dilations begin at 2 weeks postoperatively 6:52. Colostomy closure can occur 2 to 3 months after surgery once the anus has reached its desired size 6:52. The interval is not arbitrary — it reflects how long tissue remodeling takes when you've asked sphincter muscle to accept a new structure in its center.

The operation's technical challenge is not the dissection itself but maintaining orientation in a field where a wrong plane looks identical to the right one until you're already committed. The discussant's emphasis on lateral-first dissection and the fat-as-landmark principle reflects accumulated judgment about how to stay oriented when the usual visual cues are absent.

Takeaways from this story

Lateral dissection defines the anterior plane; when uncertain, return lateral where fat indicates safe proximity to rectum.
Mark the sphincter ellipse before incision—it becomes unidentifiable afterward and must be reconstructed perfectly midline.
Lower fistulas have longer common walls with urethra, making them safer via posterior sagittal than laparoscopic approach.
Muscle complex sutures should include rectal wall to prevent prolapse but position rectum adjacent to, not constricted by, muscle.

Keywords

anorectal malformation no fistula defect bulbar fistula rectoprostatic fistula rectal bladder neck fistula rectobulbar fistula rectal prolapse posterior sagittal anorectoplasty PSARP distal colostogram laparoscopic approach levator reconstruction muscle complex reconstruction anoplasty colostomy closure

Hashtags

#PediatricSurgery #AnorectalMalformation #PSARP #ColorectalSurgery

Transcript

As promised, we wanted to release a how I do it video about once a week. Today we're going to be showing a video from Dr. Mark Levitt from Nationwide Children's Hospital on how he does a posterior sagittal anal rectoplasty. We hope you enjoy. Thanks. How I do it, a posterior sagittal anorectoplasty for an anorectal malformation. In this case, we're going to show a Parp for a no fistula defect very similar to what would be used for a bulbar fistula. This is a beautiful distal cholostogram demonstrating the distal rectum with a communication to the bulbar urethra. In a no fistula defect, it looks very much like this, but no fistulous communication to the urinary tract. Obviously the key to starting any such case is a good imaging study. This one shows a recoprostatic fistula. And here you can see a rectal bladder neck fistula. I like to use this diagram to show the levels of the rectum. C would be a bladder neck fistula, essentially the deltoid. B. The triceps of this runner would be a recoprostatic fistula. And A, the elbow of the curve of the urethra or anything distal to that would be considered a recto bulbar fistula. We begin the operation in prone position with the baby well cushioned, buttocks in the air, good support for the axilla, and careful to support the feet so that the toes don't touch the bed. Here is the baby's bottom in prone position. You can see a beautiful ellipse where the sphincter is, and I like to notice this and mark it in advance. Once the posterior sagittal incision has been made, it's hard to know exactly this spot. We begin in prone position. I've marked A and B. B is the center of the sphincter. A is not. We make a perfectly centered midline incision. I'm delineating here the parasagittal fibers. We use the lone star pins for some exposure and we continue our perfect midline incision. Cutting the sphincters perfectly in the midline so that they can be easily reconstructed. At the very center there is a midline whitish structure. In this case we know it's the rectum because we have a good distal colostogram. Remember this is a case of a no fistula defect. If you don't have a good distal colostogram, this midline whitish structure could very easily be the urinary tract. We put stitches in the distal rectum like this. And are going to open perfectly in the midline so that we can now see the rectal lumen. And we continue to dissect here you see the danger area. You don't want to hurt the urethra. We continue to dissect and open this rectum until we run out of rectum anteriorly, and that's the point where there would be normally a fistula. In this case, there's no fistula. We do our lateral dissection first before we turn our attention anteriorly. That is the critical moment. You want to separate the rectum from the urinary tract below without injuring the urinary tract. This at first for a few millimeters is a submucosal dissection. Imagine you are literally dropping down the urinary tract as the rectum is lifted up. And if you want to continue your work laterally, it helps with your anterior dissection. We're checking the thickness. And the rectum is gently being lifted up off of the urinary tract below. Again, the lateral defines the anterior. If you're not sure, go lateral. When you're lateral, any fat you see means you can get closer to the rectum. And here we're lifting the rectum up. The lower the rectum is, the longer is the common wall between rectum and urinary tract. So yes, it's easier in fact that the rectum is lower, but harder because there is a longer dissection adjacent to the urethra. Clearly this is a rectum, and a bulbar would be the same. That is way too low in my opinion to approach laparoscopically, much safer to approach such an operation posterior sagittally. If you approach such a rectum laparoscopically, you are going to very likely risk leaving behind the distal rectum a remnant of the urethral fistula, a roof. So here we're closing the area where we were very close to the urinary tract. And now we begin our dissection of the rectum to gain length. We're going to lift up these bands. If you see fat, you can get closer. You must be in the correct plane, otherwise the rectum does not mobilize. And now we see where the sphincter was that we marked before. As I said, it's very helpful to mark this in advance. We close the perineal body. Which was the part of our dissection that was somewhat anterior. And now we're going to close levator to levator and muscle complex to muscle complex. For the muscle complex bites, we take a bite of the rectum, which helps to avoid prolapse. That's too deep. That stitch needs to be removed. And put above so that the rectum is lying adjacent to, not constricted by the muscle complex. And then we tie all those stitches, we repair our posterior sagittal incision, and now we can begin our anoplasty. You stitch anteriorly. As you notice, we've trimmed, we will have trimmed very little rectum. We want to preserve as much rectum as we can. And we're going to trim off this excess tissue on both sides. And do an anoplasty with 16 sutures. This anoplasty is under slight tension. So that when we cut the stitches, you will see that the rectum will gently retract in. And essentially be closed like a normal anus should appear. Dilations will begin at 2 weeks, and colostomy closure can take place 2 to 3 months from now after the anus has reached its desired size.

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