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Fig. 1 Delineation of perineal
canal by fine Hegar dilator
Fig. 2 Dissection of rectum from
vagina after laying open fistula
Fig. 3 Reconstruction of peri-
neal body and external anal
sphincter (simultaneous cutback
and posterior transposition of
anterior ectopic anus has been
done)
Fig. 4 Postoperative appearance
persistent vaginal discharge, a PC was discovered when she was
examined under anesthesia for a possible foreign body. Four patients
had an additional fistulous opening apart from the vestibule (on the
labia rnajora and perineum in 2 patients each) and 2 had an anterior
ectopic anus. Our oldest patient (aged 13 years) had been operated
upon unsuccessfully elsewhere; she presented with recurrence of the
fistula and a diverting colostomy.
Among the male patients, 3 had anoperineal fistulae and the 4th an
anourethral fistula. One of the former had an associated anal stenosis,
while the other 3 boys had an anterior ectopic anus. One female had a
septate vagina; the male with an anourethral fistula had associated
prune-belly syndrome with a fusiform megalourethra.
In 59 patients the diagnosis was established by probing the fistula
with a fine Hegar dilator (Fig. 1). The fistula originated within 1.5 cm
of the anal verge in all these cases. In the male with an anourethral
fistula a urethrocystogram was required to confirm the diagnosis and
delineate the anomaly.
The patients were categorized in three groups: group A, without
any perineal sepsis or excoriation (49/60), was treated by primary
anterior sagittal anorectoplasty (ASARP). Group B, those with perineal
excoriations but no active inflammation (7/60) underwent delayed
ASARP after management of the excoriations. Group C, with gross
perineal inflammation or abscess formation (4/60), had staged manage-
ment: laying open of the fistula and drainage of the abscesses with
perineal reconstruction 12 weeks later.
Simultaneously with the ASARR excision of the vaginal septum
and urethral plication was done in the child with a septate vagina. In
6 children (1 with anal stenosis and 5 with anterior ectopie anus), a
cutback with posterior anal transposition was undertaken, and our
oldest patient underwent colostomy closure.
Operative technique
Our technique for the correction of this anomaly is through an anterior
sagittal approach, which has recently been named ASARP by Okada et
al. [6]. The patient is kept fasting for 4 h before the operation; bowel
preparation consists of two saline enemas given 8 and 4 h before
surgery. One injection of a second-generation cephalosporin is given
with the induction of anesthesia.
The operation is performed in the lithotomy position. 1 : 150.000
epinephrine solution is infiltrated into the tissues between the fistula
and the anus with a 26-gauge needle. The perineal fistula is laid open in
the midline, exposing the edge of the rectum lying adjacent to the
vagina (Fig. 2). The anterior wall of the rectum is dissected from the
vagina until it can be brought down to the skin without tension and an
anoplasty is performed (Fig. 3). The sphincter muscle is now sutured
around the anal canal, taking "bites" of the bowel wall. The perineal
muscles are sutured between the rectum and vagina in layers, recon-
stituting the perineal body (Fig. 4). The skin is then sutured, resulting
in a normal-looking perineum. Posterior transposition of the anus, if
necessary, can be done simultaneously.
Postoperatively, the child is allowed oral feeds 4 - 6 h after surgery.
No restraint is employed, and usually no blood transfusions are
required. During convalescence the wound is kept exposed; thrice-
daily sitz baths and application of antibiotic ointment prevent infection.
Injectable antibiotics are discontinued after 72 h. The patient is usually
discharged on the 5th postoperative day.
Results
F o r t y - s e v e n of the 49 group A patients had a s m o o t h
postoperative recovery w i t h o u t a n y complications. O n e
had recurrence of the fistula; this was laid open and
s e c o n d a r y reconstruction u n d e r t a k e n after 12 weeks with
u n e v e n t f u l recovery. The 2rid patient (with p r u n e - b e l l y
s y n d r o m e ) died o f u n c o n t r o l l a b l e u r i n a r y sepsis and azote-
mia. All 7 group B patients m a n a g e d b y delayed A S A R P
had u n e v e n t f u l recoveries. Three required anal dilations for
2 weeks. T h e 4 group C patients who u n d e r w e n t s e c o n d a r y
A S A R P after drainage of perineal abscesses also had
c o m p l i c a t i o n - f r e e recovery, b u t required anal dilations for
6 weeks.
In 17 patients the tracts were subjected to histologic
e x a m i n a t i o n . In 15 the sections s h o w e d stratified s q u a m o u s
e p i t h e l i u m with subepithelial i n f l a m m a t o r y cells; in 2 there
was o n l y g r a n u l a t i o n tissue.
Fifty of the patients were seen at first f o l l o w - u p 12 weeks
after surgery. A l l were c o n t i n e n t a n d had n o r m a l defecation
w i t h o u t the use of laxatives. Thirty-four could be followed
b e y o n d the age o f 3 years. T h e y were assessed for con-