# How I Do It Levitt PSARP — GCMD Library Dr Marc Levitt from Nationwide Children's Hospital shows how he performs a posterior sagital anorectoplasty (PSARP) for a "no-fistula" anorectal malformation. See more videos like this at http://videolibrary.globalcastmd.com/how-i-do-it-levitt-psarp Type: video · 7 min · posted 2018-10-19 Canonical: https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532 ## Chapters - [0:00](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=0) Introduction and Preoperative Imaging - [1:31](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=91) Patient Positioning and Initial Incision - [2:34](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=154) Rectal Dissection and Urethral Separation - [4:51](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=291) Reconstruction and Anoplasty ## Statements - "A no fistula defect is very similar to a bulbar fistula in terms of surgical approach" — Marc Levitt (clinical) [0:20](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=20) - "The key to starting any anorectal malformation case is a good imaging study" — Marc Levitt (clinical) [0:45](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=45) - "A 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" — Marc Levitt (clinical) [1:05](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=65) - "Patient positioning requires prone position with buttocks elevated, good axillary support, and feet supported so toes don't touch the bed" — Marc Levitt (clinical) [1:31](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=91) - "The sphincter ellipse should be marked before the posterior sagittal incision because it becomes hard to identify afterward" — Marc Levitt (clinical) [1:50](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=110) - "The sphincters must be cut perfectly in the midline so they can be easily reconstructed" — Marc Levitt (clinical) [2:28](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=148) - "Without a good distal colostogram, the midline whitish structure could be urinary tract rather than rectum" — Marc Levitt (clinical) [2:42](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=162) - "The anterior dissection should continue until running out of rectum, which is the point where a fistula would normally be" — Marc Levitt (clinical) [3:09](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=189) - "Lateral dissection should be performed before turning attention anteriorly" — Marc Levitt (clinical) [3:21](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=201) - "The initial anterior dissection for the first few millimeters is a submucosal dissection" — Marc Levitt (clinical) [3:35](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=215) - "The lateral dissection defines the anterior dissection; when unsure, go lateral" — Marc Levitt (clinical) [4:07](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=247) - "When lateral, any fat seen means you can get closer to the rectum" — Marc Levitt (clinical) [4:14](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=254) - "The lower the rectum, the longer the common wall between rectum and urinary tract" — Marc Levitt (clinical) [4:23](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=263) - "Lower rectum is easier in that it is lower, but harder because there is a longer dissection adjacent to the urethra" — Marc Levitt (clinical) [4:29](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=269) - "A rectobulbar fistula is too low to approach laparoscopically and is much safer to approach posterior sagittally" — Marc Levitt (opinion) [4:38](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=278) - "Laparoscopic approach to low rectum risks leaving behind distal rectum, a remnant of the urethral fistula, or a roof" — Marc Levitt (clinical) [4:51](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=291) - "If you see fat during dissection, you can get closer to the rectum" — Marc Levitt (clinical) [5:13](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=313) - "You must be in the correct plane for the rectum to mobilize" — Marc Levitt (clinical) [5:16](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=316) - "For muscle complex bites, taking a bite of the rectum helps to avoid prolapse" — Marc Levitt (clinical) [5:44](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=344) - "The rectum should lie adjacent to, not constricted by, the muscle complex" — Marc Levitt (clinical) [5:54](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=354) - "Very little rectum should be trimmed; preserve as much rectum as possible" — Marc Levitt (clinical) [6:15](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=375) - "The anoplasty uses 16 sutures" — Marc Levitt (clinical) [6:32](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=392) - "The anoplasty should be under slight tension so that when stitches are cut, the rectum will gently retract in" — Marc Levitt (clinical) [6:36](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=396) - "Dilations will begin at 2 weeks postoperatively" — Marc Levitt (clinical) [6:52](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=412) - "Colostomy closure can take place 2 to 3 months after surgery once the anus has reached its desired size" — Marc Levitt (clinical) [6:52](https://library.globalcastmd.com/watch/how-i-do-it-levitt-psarp-532?t=412) ## 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. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai