Reoperative surgery in anorectal malformation patients

Abstract

Currently accepted primary repair of congenital anorectal malformations (ARMs) includes a posterior sagittal incision, which allows for optimal visualization and identification of important pelvic structures and anatomical features. Reconstructive surgery involves meticulous dissection and separation of pelvic structures, and careful reconstruction can result in good functional outcomes for many patients, who live without ongoing sequelae from their malformation. However, some patients may require reoperative procedures for anatomic or functional reasons. Males and females present with slightly different symptoms and should be approached differently. Males are most likely to require reoperations for anorectal or urethral pathologies, but the urinary system is often spared in females-they instead must contend with Mullerian duct anomalies, of which there are many varieties. Depending on the original malformation and severity of symptoms, redo surgery may be needed to optimize function and quality of life. Surgical management with reoperative surgery in ARMs ranges from straightforward to complex, depending on the issue. One must weigh the risks of reoperative surgery and potentially creating more scarring against the need for a better anatomical and functional outcome. Current management trends and practice patterns with regards to reoperative surgery in ARM patients are not widely studied or standardized but we provide an overview of the more common pathologies, preoperative evaluation and workup required to identify the issues, and options for reoperative repair in these patients.

Keywords: Anorectal malformation (ARM); redo surgery; reoperative.

Figure 1

Prolapse and posterior mislocation of the neoanus. The neoanus is located posterior to the perineal dimple that likely corresponds the location of the sphincter complex.

Figure 2

Neoanal stricture and anterolateral mislocation. The stricture would be readily corrected with a Heineke-Mikulicz type stricturoplasty but this patient also requires correction of his mislocation.

Figure 3

Rectal prolapse. The prolapse is not fully circumferential and can therefore be managed with a local excision.

Figure 4

Voiding cystourethrogram demonstrating the presence of a posterior diverticulum/remnant of the original fistula. B, bladder; U, urethra; R, remnant of the original fistula.

Figure 5

Absent vagina. This diagnosis is not appreciated without a close introital examination.

Figure 6

Coronal section of pelvic MRI demonstrating duplicated vagina with right sided vaginal obstruction. The right hemi-vagina (R) is significantly dilated and the left hemi-vagina (L) is nonobstructed and displaced leftwards.

Figure 7

Vaginal stenosis and mislocation and rectal posterior mislocation. This patient requires a repeat posterior sagittal anorectovaginoplasty to adequately mobilize the vagina and rectum to allow placement in its anatomic location.