Posterior Sagittal Anoplasty / PSARP with Laparotomy or Laparoscopy on Males
Colorectal Center surgeons at Cincinnati Children's Hospital Medical Center provides information about Posterior Sagittal Anoplasty / PSARP with laparotomy or laparoscopy.
Total body preparation for PSARP with laparotomy or laparoscopy.
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In these very high malformations we perform what we call "total body preparation." This consists of washing and prepping the entire body of the child, all the way from the middle portion of the chest down to and including both feet.
Both legs are usually covered with stockinnettes to maintain the baby's temperature after the preparation. In this way we have access both to the abdomen and perineum.
Posterior Sagittal Stage
The operation is started in the usual manner, posterior sagittally. A Foley catheter is inserted prior to the incision.
A foley catheter
The surgeon will be working
in a deeper field while
dividing the levator muscle.
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The surgeon will observe that the levator is usually located deeper in the wound and runs in a more horizontal manner. Therefore, the surgeon will be working in a deeper field while dividing the levator muscle.
Once the levator muscle has been divided, a rubber tube must be placed immediately behind the urinary tract and in front of the levator muscle.
The tube then will make a 90 degree angle posterior turn following the muscle complex (vertical fibers). The rubber tube must be pushed high into the presacral space and left in place. This tube simulates the presence of the rectum and will mark the desired course that the rectum should follow.
The wound is closed following the same principles discussed previously. When the posterior edge of the muscle complex is closed, of course, it is not possible to suture this to the rectum. The tube is secured in place with a heavy, temporary silk stitch.
Another alternative is the use of a Penrose drain stuffed with gauze, which has the advantage of being more pliable to follow the curves of the natural course of the rectum.
The wound is covered with gauze and a plastic sterile waterproof covering (Steri-drape™). The Foley catheter is removed.
Laparotomy
A rectum that is
already tapered.
The rectum can be pulled
through following the desired
course simply by pulling
on the rubber tube.
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We then enter the abdomen through a Pfannenstiel incision, usually lengthened on the left side in a more cephalad way ("hockey-stick" type of incision).
A new sterile Foley catheter is placed into the bladder.
As we follow the distended sigmoid in this specific type of defect, the fistula that communicates between the rectum and the urinary tract is to be found about two centimeters below the peritoneal reflection.
We opened the peritoneal reflection and keep dissecting as close as possible to the muscular layer of the bowel. As it narrows, this indicates the proximity of the fistula site.
Remember that the connection between the rectum and the urinary tract is in a T-fashion, therefore, there is no difficulty in dissecting the rectum from the urinary tract as compared with the rectobulbar and prostatic fistula.
Remember also that both vasa deferentia lie very close to the rectum. As we reach the communication between rectum and bladder, the fistula is divided with cautery; the distal bladder neck fistula is sutured with interrupted long-term sutures and the rectum is separated from the urinary tract.
The surgeon must then look for the rubber tube lying in the presacral space; the size of the tube will indicate the need for tapering of the distal rectum. The tapering must proceed in the way that has already been described.
We then suture the end of the most distal part of the intestine to the upper portion of the rubber tube and are ready to pull the rectum following the route of the rubber tube.
The rectum is pulled down attached to the rubber tube. The anoplasty will be done while the abdomen is still open.
Perineal Stage
The perineal stage of the procedure is then started and the surgeon can now appreciate the advantage of the total body preparation. The assistant keeps the legs of the patient up, and a bulky towel is placed below the pelvis of the child.
The perineum will then be lying horizontally and the procedure can be continued in a very comfortable way. The traditional two-team lithotomy position approach for abdominal and perineal operations does not make sense in small children who can be easily treated with the "total body prep" approach.
With the patient in that position, the rectum can be pulled through following the desired course simply by pulling on the rubber tube.
A smaller tube is introduced through the rectum and will be palpated into the abdomen to confirm that the surgeon did not rotate the rectum while pulling it through the tunnel.
The anoplasty will complete the operation and must be done in the way previously described. Prior to this anoplasty, an extra set of sutures may be placed, in an effort to anchor the rectum to the surrounding muscles in a deeper layer to avoid prolapse, because it is not possible to use the posterior muscle complex-anchoring sutures previously described.
The final stage
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The operator must be prepared, in this type of defect, to find very poor muscle structures.
As this occurs frequently, the prognosis is, of course, must poorer than in cases with a rectourethral fistula.
The surgeon must be more meticulous in order to identify all the muscle structures in cases with sever underdevelopment of the muscles.
Once in a while, however, for unknown reasons, a very high defect can be found with excellent muscles.
During the last years, the general tendency in pediatric surgery, has been toward minimally invasive type of prodedures. Anorectal malformations are not an exception.
We believe that very high malformations that require a laparotomy to reach a very high rectum, can be operated on laparoscopically. This will eliminate the laparotomy stage with the result of decreased pain and morbidity.
Some authors propose the use of laparoscopic procedures to repair malformations that do not require a laparotomy. We do not agree with this point of view.
We do not believe a transperitoneal approach is less invasive than a pure posterior sagittal operation.
For more information or to request an appointment, please contact the Colorectal Center at Cincinnati Children's.
