Postoperative Care for Posterior Sagittal Operation Patients
Colorectal Center surgeons at Cincinnati Children's Hospital Medical Center provide information about postoperative care for anorectal malformation patients who underwent Posterior Sagittal operations.
Medical Care | Dilations | Posterior Sagittal Operation Complications and Results
Medical Care for Posterior Sagittal Operation Patients
Patients who undergo a posterior sagittal operation generally have a smooth postop course. The incision is relatively painless considering the extent of surgery that was done.
We attribute this to the fact that the operation is done through a midline incision, and most probably no nerve endings are divided.
Foley catheters in those cases with urinary fistula must remain in place between five and 14 days. Five days will be adequate for a typical rectourethral bulbar fistula, and up to two weeks are needed for a complicated or complex cloaca.
In complex cloacas, a formal suprapubic cystostomy is recommended rather than inserting a Foley catheter.
We believe that the presence of a foreign body in the urethra for longer periods of time will not only fail to prevent strictures, but may act as a foreign body, causing irritation and increasing the inflammatory rectourethral fistulas in males.
If the catheter comes out before five days, it is better to leave it out rather than risk tearing the sutures in the posterior urethra by trying to recatheterize the child.
An enthusiastic resident could cause more damage trying to replace the catheter. Most patients will void spontaneously without further consequences.
On a few occasions, the patient could not void, and a percutaneous suprapubic tube was inserted and left in place for three to five days.
Bacitracin ointment is used three times a day on the wound site. Antibiotics, including ampicillin and gentamicin, should be administered intravenously, usually 24 to 72 hours.
After that period, provided the patient is doing well and no manifestation of infection is seen, we suggest stopping the intravenous antibiotics and continuing with ampicillin by mouth.
In specific cases in which the colostomy was not completely diverting and therefore gross fecal contamination occurred during the operation, we give a more aggressive treatment for one week postop with:
- Ampicillin
- Gentamicin
- Clindamycin
Those patients whose abdomen was also opened in order to repair a very high defect, in addition to the postop care already described, may need a nasogastric tube for a variable period, usually 48 to 96 hours, until there is evidence that the bowel is working well.
A child who underwent a posterior sagittal operation without having had the abdomen opened, may receive oral feedings on the day of surgery.
They can be discharged after 48 hours, whereas the patients with laparotomy may spend a few more days in the hospital.
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We encourage the parents of children who undergo this type of procedure to buy a set of Hegar dilators. Two weeks after the operation, the child is brought to the clinic.
The main subcuticular suture is removed and the anus is calibrated with increasing sizes of Hegar dilators until we pass the one that fits snuggly in the anus. We then teach the mother how to pass this dilator and we instruct her to do it twice a day.
Every week, the size of the dilator must be changed to the next size one. The parents are encouraged to do it themselves at home but if they have difficulty, it can be done at the hospital. This process of dilatation continues until the desired size is reached.
Age of Child | Hegar Dilator |
| 1 to 4 months old | # 12 |
| 4 to 12 months old | # 13 |
| 8 to 12 months old | # 14 |
| 1 to 3 years old | # 15 |
| 3 to 12 years old | # 16 |
| More than 12 years | # 17 |
When the desired size is reached, the colostomy may be closed but the process of dilatations must continue, gradually tapering the frequency of dilatations.
Once the mother says the desired-size dilator goes in easily with no pain, the frequency of dilatations can be tapered according to the following program:
- Once a day for one month
- Every third day for one month
- Twice a week for one month
- Once a week for one month
- Once a month for three months
Dilatations are much easier on young babies, but may be painful when the larger sizes are reached. However, mothers have stated that the pain only lasts for a few days, then subsides, and the dilatation becomes painless.
At any time during the process of tapering the frequency of dilatations, if the dilatation becomes difficult, painful, or bloody, this is a specific indication to dilate twice a day again and restart the process.
Difficult dilatations can be co-related with operations in which the distal rectum was devascularized. A frequent error in anal dilatations consists of trying to avoid hurting the child and dilating only once a week under anesthesia or sedation.
Under those circumstances, the surgeon causes a laceration each week; the laceration then heals and is reopened during the next dilatation.
By doing this, a severe fibrotic ring is created which then becomes intractable. Also, staying on the same dilator for more than one week will promote the healing of the anus with a small caliber which will make it more difficult to dilate later on.
The rationale behind dilatations consists of appreciation of the fact that the anus and the rectum are surrounded by muscle structures and therefore remain closed at rest, particularly in cases with good muscles.
Thus, if the patient is not dilated, the anus will tend to heal closed or very narrowly.
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Complications of posterior sagittal procedures in the management of anorectal malformations include:
- Wound infection
- Anal stricture
- Anorectal stricture
- Urethrovaginal fistula (in cases of cloaca and prior to the urogenital mobilization)
- Transient femoral nerve pressure palsy
- Recurrent rectourethral fistula
- Fibrosis and retraction of the vagina in the repair of a persistent cloaca
Urethral injury - Vas deferens injury
In addition to these complications, there are complications related to the opening of a colostomy as well as to its closure.
In the author's entire series, four patients suffered from wound infections during the postoperative period of a posterior sagittal repair, three of them had a loop colostomy which probably was not completely diverting.
Not having a completely diverting colostomy seems to be statistically significant, increasing the chances of having a wound infection.
In addition, the surgeon must be very gentle in the management of the tissues; no dead spaces must be left and hemostasis must be very meticulous if infection is to be avoided.
Only one patient required the placement of a Penrose drain after one of these operations.
Anal and anorectal strictures are due most likely to ischemia of the rectum; only one anorectal stricture has been seen in the entire series. Anal stricture on the other hand, in the absence of an ischemia, can be produced also by lack of anal dilatations.
Remember, surgery of the anus and rectum is peculiar, particularly in cases with good muscles where the new anus will remain closed due to the muscle effect. If the anus is not dilated, it will heal in that position, provoking an anal stricture.
The protocol of anal dilatation must be scrupulously followed to avoid this complication. Urethrovaginal fistula occurred in six of 54 cloacas operated on by the author prior to the urogenital mobilization.
Transient femoral nerve pressure palsy was observed in three adolescent patients subjected to a secondary posterior sagittal approach; this was due to pressure in the groin because of the patients' position (prone with the pelvis elevated).
It has never been seen in younger patients. The patients recovered uneventfully and the symptoms disappeared. We have learned to be meticulous about padding and cushioning the groins during these operations.
One of the author's patients, who was subjected to a secondary posterior sagittal anorectoplasty, suffered a recurrent rectourethral fistula which closed spontaneously after several weeks of observation. That patient had a foreign body (Penrose) left from the previous procedure.
Fibrosis and retraction of the vagina after the cloaca repair can occur while persisting in the dissection of a very high vagina.
This complication can be avoided by the rationale use of some form of vaginal replacement. We have not seen this complication in cases in whom the total urogenital mobilization was used.
An ectopic ureter can be injured, as happened in two of our cases, while looking for a very high rectum through the sagittal approach. This can be avoided with a good distal colostogram.
In our cases it would have shown that the rectum opened at the bladder neck and we would not have looked for it through this approach but rather through the abdomen. The vas deferens was injured in two cases for the same reason as described for the ureter.
There is a large series of urologic injuries produced by the posterior sagittal approach. Recently, we reviewed our records and found significant urologic injuries performed at other institutions.
These included neurogenic bladder (permanent), complete transection of the posterior urethra, pull-through of the bladder, pull-through of a megaureter, and creation of a rectourethral fistula that was not present prior to the operation. All these complications occurred in patients that were approached posterior sagittally, without an adequate distal colostogram.
The surgeon did not know where the rectum was located. Most of these patients had the rectum located at a position in the pelvis that was not reachable posterior sagittally. The surgeon entered posterior sagittally, looking for a rectum that was not there.
During the search, the surgeon divided vas deferens or found a midline whitish stricture which he mistook for the rectum, and divided the urethra, and/or pulled down the entire urogenital tract including bladder and ureters.
We therefore concluded that a posterior sagittal operation should never be performed without a good previous high-pressure distal colostogram.
If the distal colostogram shows a rectum that opens in the bladder neck, the surgeon should know that the rectum is simply not reachable posterior sagittally and therefore the patient will need a laparotomy or laparoscopy to reach the rectum.
Finding "more muscle in one side" than in the other is not an anatomical defect but rather an error in technique. Most likely, the surgeon failed to stay exactly in the midline.
Inability to bring the rectum down to the perineum, in spite of the fact that the surgeon found it, may be due to lack of adequate technique for the circumferential dissection that allows the mobilization of the rectum.
Otherwise, the surgeon must suspect that the patient has a very distal colostomy which fixed the distal portion of the intestine thus interfering with the pull-through.
The last complication can be avoided doing a distal colostogram as a routine, which will inform us about the length of available intestine.
The results in the surgical treatment of patients suffering from cloaca, dependeded on the quality of the sacrum and the length of the common channel. We have never seen a patient with bowel control with a sacral ratio less than 0.3.
Urinary control depends mainly on the length of the common channel. Patients with a common channel longer than 3 centimeters, require intermittent catheterization to empty the bladder in 80 percent of the cases.
This maneuver is necessary only in 20 percent of the patients that were born with a common channel shorter than three centimeters 60 percent of the patients have voluntary bowel movements, and 40 percent of the patients are fecally incontinent but they remain clean when subjected to an adequate bowel management program.
Patients subjected to secondary operations to repair sequalae from complications suffered during previous attempted repairs had dramatically good results in restoring their anatomy.
In terms of bowel function, the results were slightly inferior to the ones achieved in the same defect with a primary operation.
Patients with normal sacrums, who underwent secondary operations for the treatment of fecal incontinence achieved marked improvement in 45 percent of the cases, some improvement in 37 percent, and no improvement in 18 percent.
In contrast, those with abnormal sacrum achieved 20, 30 and 50 percent respectively, in each of the above-mentioned categories.
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For more information or to request an appointment, please contact the Colorectal Center at Cincinnati Children's.
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