Anterior Sagittal Anorectoplasty: Our Experience

Abstract

Context: Anterior sagittal anorectoplasty (ASARP) is accepted as one of the techniques for the repair of vestibular fistula (VF) and low-type anomalies, but some may have reservations.

Aims: The aim of the study is to describe the technique, important features, and functional and cosmetic outcomes of ASARP for the treatment of anorectal malformation (ARM) in females.

Settings and design: A prospective study was performed from 1992 to 2017.

Materials and methods: The study included 157 pediatric patients (aged 1-15 years) with diagnosis of ARMs with VF, perineal fistula (perineal ectopic anus), and rectovaginal fistula managed by ASARP.

Results: Most cases (36.94%) were 1-6 months' age group; 92.99% of patients (146) were having VF, 5.09% (8) perineal fistula, and 1.91% (3) rectovaginal fistula. Associated anomalies (37) were present in 19.75% (31) of patients. Primary ASARP was performed in 85.35% (134) of cases. The mean operative time was 105 (±15) min. Intraoperative complications were seen in 3.82% (6) of patients. Early postoperative complications were seen in 5.09% (8) of patients - wound infection (4), wound dehiscence (3), and retraction of the rectum (1). Late complications were seen in 12.73% (20) of cases. Overall, five patients developed anal stenosis, two responded to dilatation therapy, and three required anoplasty. The external appearance of the perineum after the 3^rd month (postoperatively) was satisfactory in 95.54% (150); overall, 4.46% (7) of patients required the second procedure. Stooling pattern could be assessed in 80.25% (126) of patients at 3 years' age group. Only one had poor outcome with severe soiling (incontinence) and perineal excoriation that also had myelomeningocele.

Conclusions: ASARP is an excellent procedure for VF as it results in optimal correction with minimal sphincteric damage, without additional complexity or difficulties. Primary ASARP is a quick and effective technique and does not require colostomy if performed after due preoperative gut preparation and by an experienced pediatric surgeon.

Keywords: Anorectal malformation; anterior sagittal anorectoplasty; outcomes; perineal fistula; rectovaginal fistula; vestibular fistula.

Figure 1

Intraoperative photographs showing patient (catheterized) of vestibular fistula placed in supine position with elevation of lower back to ensure good access to the perineal area; stay sutures are taken for better demonstration of operating field (on right)

Figure 2

Preoperative photographs showing perineal fistula (on left) and fourchette fistula (on right)

Figure 3

Intraoperative photographs showing posterolateral dissection of vestibular fistula (on left); complete mobilization of the rectum (on right)

Figure 4

Intraoperative photographs showing complete (adequate) mobilization of the rectum with divided external sphincter (on top); rectum pulled through between the preserved external sphincters (below)

Figure 5

Photographs taken at the completion of anterior sagittal anorectoplasty (on left) showing small perineal wound between 5^th and 10^th postoperative periods

Figure 6

Postoperative photographs with small scar and satisfactory cosmetic outcome