# The Perineal Body Preserving PSARP (PPP) — GCMD Library Children's National Hospital - Division of Colorectal and Pelvic Reconstruction  Type: video · 11 min · posted 2026-06-03 Canonical: https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116 ## Chapters - [0:00](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=0) Case presentation and anatomic classification - [2:03](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=123) Operative setup and initial dissection - [3:18](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=198) Rectal mobilization and anterior dissection - [6:39](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=399) Completion of rectal mobilization and anoplasty - [10:08](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=608) Fistula closure ## Statements - "The patient is a female infant born with an anorectal malformation and a rectovesibular fistula." (clinical) [0:05](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=5) - "Examination reveals a normal introitus with the rectum ending as a fistula in the vestibule and a pink sphincteric ellipse." (clinical) [0:12](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=12) - "For 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." (clinical) [0:22](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=22) - "With all anorectal malformations, it is vital to inspect for any associated anomalies." (guideline) [1:03](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=63) - "In females with anorectal malformation, vaginoscopy is performed to look for associated Mullerian anomalies such as vaginal septum, distal vaginal atresia, and uterine anomalies." (guideline) [1:10](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=70) - "In this case, vaginoscopy showed a normal vagina and a single cervix." (clinical) [1:10](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=70) - "The 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." (clinical) [1:31](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=91) - "The perineal body preserving technique (PPP) is an alternative to traditional PSARP." (clinical) [1:58](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=118) - "An electrical stimulator (the same one used by anesthesia for train of four) can define the extent of the sphincter complex." (clinical) [2:11](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=131) - "For the electrical stimulator to work well, muscle relaxation must be avoided." (clinical) [2:26](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=146) - "In the PPP technique, the entire incision need only be the extent of the sphincter; no posterior and no anterior incision is needed." (clinical) [2:35](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=155) - "Care must be taken that retractors do not split the perineal body inadvertently." (clinical) [2:45](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=165) - "A suture is placed at the anteriormost extent of the intended anoplasty to help avoid inadvertent splitting of the perineal body." (clinical) [2:50](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=170) - "In the PPP, the perineal body is not incised." (clinical) [3:13](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=193) - "The lateral aspects of the rectum are intimately attached to the vaginal wall and must be dissected with great care to avoid injury." (clinical) [3:33](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=213) - "A helpful concept is to think of the PPP like a bulbar fistula repair in a male with anorectal malformation." (opinion) [3:43](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=223) - "A stitch is placed in the fistula, analogous to the approach for a bulbar fistula." (clinical) [3:59](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=239) - "Placement 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." (clinical) [4:20](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=260) - "The rectum is mobilized and dissected within the whitish fascia that envelops it." (clinical) [8:32](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=512) - "A Hagar dilator in the vagina facilitates dissection of the rectum from the vagina." (clinical) [8:41](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=521) - "The stitch on the fistula is passed into the introitus and the fistula tissue is managed at the end of the case." (clinical) [8:50](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=530) - "The perineal body muscles are sutured together where the fistula used to be, forming the sphincter anterior to the new anoplasty." (clinical) [9:00](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=540) - "The anoplasty is placed within the initial incision, which is the center of the sphincters." (clinical) [9:09](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=549) - "In the PPP technique, no sutures are needed in the perineal body's skin; the perineal body skin is untouched." (clinical) [9:15](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=555) - "The rectum is split on its anterior and posterior wall." (clinical) [9:23](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=563) - "The anoplasty is completed with 16 absorbable sutures placed full thickness, rectal wall to anal skin." (clinical) [9:27](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=567) - "After completion of the anoplasty, the patient is turned supine and the introitus is exposed." (clinical) [10:08](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=608) - "The fistula tissue is excised and the mucosa of the vestibule is repaired where the fistula had been." (clinical) [10:27](https://library.globalcastmd.com/watch/the-perineal-body-preserving-psarp-12116?t=627) ## 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. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai