How I Do It Levitt PSARP

As promised, we wanted to release a how I do it video about once a week. Today we're gonna be showing a video from Doctor 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 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, um, 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. 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, uh, 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.