Posterior Sagittal Anorectoplasty (PSARP) for Females with Rectovestibular Fistulae
The staff of the Colorectal Center at Cincinnati Children's Hospital Medical Center provides information about Posterior Sagittal Anorectoplasty (PSARP) for females with rectovestibular fistulae.
Traction Sutures
Rectum Separated
Perineal Body Closed
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The operation is started by placing multiple 6-0 silk stitches at the mucocutaneous junction of the fistula.
The incision is similar to the one already described for the case of a cutaneous fistula except that it is extended more cephalad. It is also "racket-like" and surrounds the fistula; it proceeds through:
- The skin
- Subcutaneous tissue
- Parasagittal fibers
- The muscle complex
It is not necessary to divide the levator muscle, except perhaps in its lowest portion.
The most important part of the operation is the dissection of the rectum, particularly in its anterior aspect where rectum and vagina share a common wall. Patience and meticulous attention are required to perform this rectovaginal dissection. The dissection is continued up to the point where rectum and vagina separate and have full thickness walls.
The most frequent error in performing this operation is that the vagina and the rectum are not completely separated. The consequences are a tense anastomosis between the rectum and the skin, and a patent common wall between rectum and vagina which will pull the rectum back to its original position, causing the rectovestibular fistula to reoccur.
Once the dissection has been completed, the perineal body is repaired and the anterior edge of the muscle complex is reapproximated putting together its anterior limit as well as the one of the external sphincter.
Then, the posterior edge of the muscle complex is reapproximated bringing together the posterior limit of the external sphincter and anchoring the muscle to the rectum. The anoplasty is done in the same way as previously described.
Occasionally, there may be a case of a long narrow fistula that cannot be used for creating the new anus because of its narrow diameter. In such a case, the dissection must continue higher to gain enough bowel length to allow the narrow portion of intestine to be discarded so that a more successful anoplasty can be created with a better caliber anus within the limits of the sphincter. Ampicillin and gentamicin are given at the time of surgery and continued for forty eight hours post-op.
The posterior edge of the muscle complex is reapproximated bringing together the posterior limit of the external sphincter and anchoring the muscle to the rectum. The anoplasty is then done in the same way as previously described.
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