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The Perineal Body Preserving PSARP (PPP)

Video Published 2026-06-03 Updated 2026-08-01

Timestops (18)

The perineal body preserving PSAP, PPP.

The perineal body preserving PSAP, PPP. We present a case of a patient born with an interectal malformation and a recive…

For females with an anorectal malformation

For females with an anorectal malformation, the options anatomically include 1, a recto vestibular fistula, 2, a rectooc…

Anal stenosis, and 6, the anatomy can be slightly anteriorly located, but otherwise is a normal anus. With all interecta…

You are looking for any associated Mullerian anomalies

You are looking for any associated Mullerian anomalies, such as a vaginal septum, distal vaginal atresia, and a variety …

This includes incising a long posterior sagittal incision fr…

This includes incising a long posterior sagittal incision from the coccyx down, mobilizing the rectum off of the posteri…

Here you see the clitoris

Here you see the clitoris, the introitis, and the vestibular fistula. The sphincteric ellipse is more pink, and the elec…

Here you see us marking the sphincter.

Here you see us marking the sphincter. The entire incision need only be the extent of the sphincter. No posterior and no…

Here you see us opening the incision in the midline.

Here you see us opening the incision in the midline. We use lone star pins to gain exposure, and we continue our dissect…

Sutures are now placed full thickness in the rectal wall.

Sutures are now placed full thickness in the rectal wall. These are used for circumferential traction. The lateral aspec…

Once the lateral sizes of the rectum had been dissected and …

Once the lateral sizes of the rectum had been dissected and the posterior rectal wall opened, you must now define the an…

And now you see placement of multiple sutures across the ant…

And now you see placement of multiple sutures across the anterior lip of the rectal wall. This is a vitally important st…

Now we continue the dissection of the lateral walls of the r…

Now we continue the dissection of the lateral walls of the rectum, which sets us up for the anterior rectal wall dissect…

And now it's time to come across the anterior

And now it's time to come across the anterior, lifting the rectum up and dropping the fistula and the vagina down.

Now with the rectum separated

Now with the rectum separated, we mobilize it, we dissect it within the whitish fascia that envelops the rectum. A Hagar…

The perineal body muscles are sutured together where the fis…

The perineal body muscles are sutured together where the fistula used to be, and this will form the sphincter anterior t…

And the anoplasty completed with 16 absorbable sutures.

And the anoplasty completed with 16 absorbable sutures. These sutures are placed full thickness, rectal wall to anal ski…

After completion of the anoplasty

After completion of the anoplasty, the patient is turned supine and the introitus exposed with the Lone Star hooks. You …

And now we have concluded the operation.

Topic Overview

This is a technical surgical demonstration of the perineal body preserving posterior sagittal anorectoplasty (PPP) for repair of a rectovesibular fistula in a female infant with anorectal malformation. The technique differs from the traditional PSARP by avoiding incision of the perineal body; instead, the rectum is mobilized by splitting its anterior and posterior walls and dissecting it off the vagina, analogous to repair of a bulbar fistula in males. The anoplasty is placed within the sphincter complex identified by electrical stimulation, and the vestibular fistula is subsequently closed transvaginally.

Key Takeaways

PPP avoids perineal body incision by splitting rectal walls and dissecting off vagina, analogous to male bulbar fistula repair. (1:58)
Electrical stimulation defines sphincter extent for incision placement; muscle relaxation must be avoided for accuracy. (2:11)
Multiple sutures across anterior rectal wall are vital to lift rectum and facilitate safe dissection from posterior vaginal wall. (4:20)
Vaginoscopy is essential in female ARM to identify Mullerian anomalies like vaginal septum or uterine abnormalities. (1:10)
Fistula closure is completed transvaginally after anoplasty; perineal body skin remains untouched in PPP technique. (9:15)

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

Chapters

0:00Case presentation and anatomic classification — Introduction of a female infant with rectovesibular fistula. Review of the six anatomic variants of female anorectal malformations and the importance of assessing for associated Mullerian anomalies. Contrast between traditional PSARP (which incises the perineal body) and the perineal body preserving technique.
2:03Operative setup and initial dissection — Demonstration of anatomy and use of electrical stimulation to map the sphincter complex without muscle relaxation. Marking of the sphincter extent to define the incision. Placement of a suture at the anterior limit to prevent inadvertent splitting of the perineal body. Opening of the midline incision and initial dissection posterior to the rectal wall.
3:18Rectal mobilization and anterior dissection — Division of the rectal wall and placement of circumferential traction sutures. Lateral dissection of the rectum off the vagina. Conceptual analogy to bulbar fistula repair in males. Placement of sutures in the anterior rectal lip to facilitate separation from the vagina.
6:39Completion of rectal mobilization and anoplasty — Final separation of rectum from vagina and fistula. Mobilization of rectum within its fascial envelope. Closure of perineal body muscles where the fistula had been. Formation of the anoplasty within the sphincter complex using 16 absorbable full-thickness sutures, without any incision of perineal body skin.
10:08Fistula closure — Patient repositioned supine. Excision of the vestibular fistula tissue and repair of the vestibular mucosa.

Key claims

0:05The patient is a female infant born with an anorectal malformation and a rectovesibular fistula. — Speaker 1
0:12Examination reveals a normal introitus with the rectum ending as a fistula in the vestibule and a pink sphincteric ellipse. — Speaker 1
0:22For 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. — Speaker 1
1:03With all anorectal malformations, it is vital to inspect for any associated anomalies. — Speaker 1
1:10In females with anorectal malformation, vaginoscopy is performed to look for associated Mullerian anomalies such as vaginal septum, distal vaginal atresia, and uterine anomalies. — Speaker 1
1:10In this case, vaginoscopy showed a normal vagina and a single cervix. — Speaker 1
1:31The 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. — Speaker 1
1:58The perineal body preserving technique (PPP) is an alternative to traditional PSARP. — Speaker 1
2:11An electrical stimulator (the same one used by anesthesia for train of four) can define the extent of the sphincter complex. — Speaker 1
2:26For the electrical stimulator to work well, muscle relaxation must be avoided. — Speaker 1
2:35In the PPP technique, the entire incision need only be the extent of the sphincter; no posterior and no anterior incision is needed. — Speaker 1
2:45Care must be taken that retractors do not split the perineal body inadvertently. — Speaker 1
2:50A suture is placed at the anteriormost extent of the intended anoplasty to help avoid inadvertent splitting of the perineal body. — Speaker 1
3:13In the PPP, the perineal body is not incised. — Speaker 1
3:33The lateral aspects of the rectum are intimately attached to the vaginal wall and must be dissected with great care to avoid injury. — Speaker 1
3:43A helpful concept is to think of the PPP like a bulbar fistula repair in a male with anorectal malformation. — Speaker 1
3:59A stitch is placed in the fistula, analogous to the approach for a bulbar fistula. — Speaker 1
4:20Placement 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. — Speaker 1
8:32The rectum is mobilized and dissected within the whitish fascia that envelops it. — Speaker 1
8:41A Hagar dilator in the vagina facilitates dissection of the rectum from the vagina. — Speaker 1
8:50The stitch on the fistula is passed into the introitus and the fistula tissue is managed at the end of the case. — Speaker 1
9:00The perineal body muscles are sutured together where the fistula used to be, forming the sphincter anterior to the new anoplasty. — Speaker 1
9:09The anoplasty is placed within the initial incision, which is the center of the sphincters. — Speaker 1
9:15In the PPP technique, no sutures are needed in the perineal body's skin; the perineal body skin is untouched. — Speaker 1
9:23The rectum is split on its anterior and posterior wall. — Speaker 1
9:27The anoplasty is completed with 16 absorbable sutures placed full thickness, rectal wall to anal skin. — Speaker 1
10:08After completion of the anoplasty, the patient is turned supine and the introitus is exposed. — Speaker 1
10:27The fistula tissue is excised and the mucosa of the vestibule is repaired where the fistula had been. — Speaker 1

Cases discussed

0:05Female infant with anorectal malformation and rectovesibular fistula repaired using perineal body preserving PSARP.

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.

Perineal Body Preserving PSARP: Surgical Technique and Anatomic Principles

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

The perineal body preserving posterior sagittal anorectoplasty (PPP) represents a departure from traditional PSARP by avoiding incision of the perineal body entirely. Understanding when and how to apply this technique requires clarity about female anorectal malformation anatomy and a conceptual shift in how the repair is approached.

Anatomic Classification Drives Surgical Planning

Female anorectal malformations present in six anatomic variants: 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 0:22. The rectovesibular fistula — where the rectum ends as a fistula in the vestibule with a normal introitus and pink sphincteric ellipse — is the variant addressed by PPP [c1, c2]. Before proceeding with any repair, vaginoscopy must be performed to identify Mullerian anomalies including vaginal septum, distal vaginal atresia, and uterine anomalies 1:10. This is not optional screening; it is vital to inspect for associated anomalies with all anorectal malformations 1:03.

Electrical Mapping Defines the Surgical Field

The sphincter complex must be precisely identified before incision. An electrical stimulator — the same device anesthesia uses for train-of-four monitoring — can define the sphincter's extent 2:11. This works only if muscle relaxation is avoided 2:26. In PPP, the entire incision need only span the sphincter; no posterior extension to the coccyx and no anterior extension into the perineal body are required 2:35. A suture placed at the anteriormost extent of the intended anoplasty prevents inadvertent splitting of the perineal body during retractor placement 2:50. The perineal body itself is never incised 3:13.

Think of This as a Bulbar Fistula Repair

The conceptual framework that makes PPP intelligible is to approach it like a bulbar fistula repair in a male with anorectal malformation 3:43. A stitch is placed in the fistula, just as it would be for a bulbar fistula 3:59. The critical technical step follows: multiple sutures are placed across the anterior lip of the rectal wall 4:20. This is vitally important because it facilitates lifting of the rectal wall and separation from the posterior vaginal wall 4:20. Without these sutures, the dissection becomes significantly more difficult and the risk of vaginal injury increases.

Dissection Planes and Vaginal Protection

The lateral aspects of the rectum are intimately attached to the vaginal wall and must be dissected with great care to avoid injury 3:33. The rectum is mobilized within the whitish fascia that envelops it 8:32. A Hagar dilator placed in the vagina facilitates this dissection by providing countertension and defining the plane 8:41. Once the rectum is fully separated, the stitch on the fistula is passed into the introitus; the fistula tissue itself is managed at the end of the case 8:50.

Reconstruction Without Perineal Body Incision

The perineal body muscles are sutured together where the fistula used to be, forming the sphincter anterior to the new anoplasty 9:00. The anoplasty is placed within the initial incision, which is the center of the sphincters 9:09. No sutures are needed in the perineal body's skin; the perineal body skin is untouched 9:15. The rectum is split on its anterior and posterior wall 9:23, and the anoplasty is completed with absorbable sutures placed full thickness, rectal wall to anal skin 9:27. After the anoplasty is complete, the patient is turned supine, the introitus is exposed, the fistula tissue is excised, and the mucosa of the vestibule is repaired where the fistula had been 8:50.

The Central Insight

The PPP technique preserves the perineal body by recognizing that the rectovesibular fistula can be approached through the sphincter complex itself, without dividing the tissue bridge between vagina and anus. The anterior sutures on the rectal wall are the technical key; the bulbar fistula analogy is the conceptual key. Together they allow a repair that leaves the perineal body intact.

Takeaways from this story

Electrical stimulation maps the sphincter complex, but only works if muscle relaxation is avoided during the procedure.
Multiple sutures across the anterior rectal wall are vitally important for lifting and separating the rectum from the vagina.
PPP is conceptually similar to bulbar fistula repair: place a stitch in the fistula and work within the sphincter complex.
The perineal body skin remains untouched in PPP; the anoplasty is completed within the sphincter incision without perineal body sutures.
All female anorectal malformations require vaginoscopy to identify Mullerian anomalies before proceeding with repair.

Keywords

anorectal malformation rectovesibular fistula rectocloacal fistula rectoperitoneal fistula anal stenosis vaginal septum distal vaginal atresia uterine anomalies Mullerian anomalies bulbar fistula posterior sagittal anorectoplasty PSARP perineal body preserving PSARP PPP vaginoscopy

Transcript

The perineal body preserving PSAP, PPP. We present a case of a patient born with an interectal malformation and a recive vestibular fistula. Examination of the baby reveals a normal introitis with the rectum ending as a fistula in the vestibule and a pink sphincteric ellipse. For females with an anorectal malformation, the options anatomically include 1, a recto vestibular fistula, 2, a rectoochette fistula 3, a recto perineal fistula where the fistula is in the center of the perineal body 4, a recto perineal fistula where the fistula is within the sphincteric complex but at its anteriormost extent. 5. Anal stenosis, and 6, the anatomy can be slightly anteriorly located, but otherwise is a normal anus. With all interectal malformations, it is vital to inspect for any associated anomalies. In females, we perform a vaginoscopy, which shows, in this case, a normal vagina and a single cervix. You are looking for any associated Mullerian anomalies, such as a vaginal septum, distal vaginal atresia, and a variety of uterine anomalies. The traditional P harp is done in prone position with cutting of the perineal body down to the vestibular fistula. This includes incising a long posterior sagittal incision from the coccyx down, mobilizing the rectum off of the posterior wall of the vagina, and then repairing the perineal body, which has been cut before completing the anoplasty, and then closure of the posterior sagittal incision. The operation we show in this video is the perineal body sparing technique, the PPP. We begin by re-demonstrating the anatomy. Here you see the clitoris, the introitis, and the vestibular fistula. The sphincteric ellipse is more pink, and the electrical stimulator can define its extent. This stimulator is the same one used by our anesthesia colleague for their train of four. To detect how much muscle relaxant they have on board. Remember, in order for this stimulator to work well, muscle relaxation must be avoided. Here you see us marking the sphincter. The entire incision need only be the extent of the sphincter. No posterior and no anterior incision is needed in setting up the PPP. You need to be careful that the retractors don't split the perineal body inadvertently. To help avoid this, a suture is placed at the anteriormost extent of the intended anoplasty. Here you see us opening the incision in the midline. We use lone star pins to gain exposure, and we continue our dissection posterior to the rectal wall and we place the pins deeper. Here you see the rectal wall nicely defined. Note that the perineal body has not been incised. Sutures are placed in the rectal wall on either side of the midline, and the rectal wall is divided, so the anterior aspect can be easily seen. Sutures are now placed full thickness in the rectal wall. These are used for circumferential traction. The lateral aspects of the rectum are dissected, taking great care not to injure the vaginal wall to which it is intimately attached. A very helpful concept is to think of the PPP like you would a bulbar fistula in a male with ARM. Once the lateral sizes of the rectum had been dissected and the posterior rectal wall opened, you must now define the anterior rectal wall. You will notice that there is a stitch placed in the fistula, just like one would for a bulbar fistula. And now you see placement of multiple sutures across the anterior lip of the rectal wall. This is a vitally important step because it facilitates the lifting of the rectal wall up and the separation of it from the posterior rectal wall. Now we continue the dissection of the lateral walls of the rectum, which sets us up for the anterior rectal wall dissection. First one side, then the other side. And now it's time to come across the anterior, lifting the rectum up and dropping the fistula and the vagina down. Now with the rectum separated, we mobilize it, we dissect it within the whitish fascia that envelops the rectum. A Hagar dilator in the vagina facilitates this dissection. And now you see the rectum is fully separated from the vagina. That stitch on the fistula now becomes very important. We pass it into the introitus, and we will manage this fistula tissue at the end of the case. The perineal body muscles are sutured together where the fistula used to be, and this will form the sphincter anterior to the new anoplasty. The anoplasty is now formed and placed within the initial incision, which is the center of the sphincters. In this technique, no sutures are needed in the perineal body's skin. The perineal body skin was untouched. The rectum is split on its anterior and posterior wall. And the anoplasty completed with 16 absorbable sutures. These sutures are placed full thickness, rectal wall to anal skin. After completion of the anoplasty, the patient is turned supine and the introitus exposed with the Lone Star hooks. You see the fistula on the silk stitch. This tissue is then excised and the mucosa of the vestibule repaired where the fistula had been. And now we have concluded the operation.

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