Transfistula anorectoplasty on adult female anorectal malformation: A rare case report

Abstract

Introduction: Female anorectal malformation (ARM) is correctable congenital defects. Delayed presentation of patients with anorectal malformation is uncommon. However, presentation beyond teenage years is not commonplace. We describe a case of ARM with rectovestibular fistula and anal atresia.

Presentation of case: A 31 years old woman with chief complaint of small vaginal introitus. Gynecology examination showed urethra, labia majora, labia minora, and small vaginal introitus. Vaginal length was 6 cm. There was no anal canal. The patient underwent transfistula anorectoplasty and modified Fenton procedure.

Discussion: The important step of transfistula anorectoplasty (TFARP) procedure is the placement of neoanus in the center of external spinchter to provide continence. The absence of skin incision in anterior and posterior to the neoanus provide good cosmetic result. Compared to PSARP procedure, TFARP procedure has advantage which is the absence of separation of the skin in the midline buttock, the levator muscle, and the external spinchter complex. This lead to optimal fecal continence. In our experience, TFARP is a safe and effective procedure. Daily vaginal dilation in postoperative period is unnecessary. This technique also give good cosmetic result with optimal fecal continence and sexual function.

Conclusion: Transfistula anorectoplasty procedure for ARM give give good cosmetic result and optimal fecal continence and sexual function.

Keywords: Anorectal malformation; Surgical technique; Transfistula anorectoplasty.

Fig. 1

Anovestibular fistula with openings of urethra and vagina. There was no anal opening.

Fig. 2

Ultrasonography.

Fig. 3

Transfistula anorectoplasty technique (A). Circumference incision was performed in vestibule. Several fine silk traction sutures insertion around the fistula orifice. (B) Separation of the rectum from the posterior vaginal wall was conducted by sharp dissection. Meticulous dissection of anorectum about 4 to 5 cm length was performed to prevent vaginal damage or musculature surrounding the rectum. Spinchter muscle was identified and by using the index finger as a marker, v-shaped incision is made through the anal canal. (C) Anoplasty was performed with apposition of vestibular wound using PGA 3.0. (D). Rectal tube number 11 was inserted, vagina and perineal body was reconstructed with modified Fenton procedure; vestibular wound was closed with PGA 2.0 interrupted stitches, bulbospongiosus muscle was sutured using PGA 2.0 and posterior vaginal mucose was sutured using PGA 2.0.

Fig. 4

Three months follow up.