Sphincter saving anorectoplasty (SSARP) for the reconstruction of Anorectal malformations

<p>Abstract</p> <p>Background</p> <p>This report describes a new technique of sphincter saving anorectoplasty (SSARP) for the repair of anorectal malformations (ARM).</p> <p>Methods</p> <p>Twenty six males with high ARM were treated with SSARP. Preoperative localization of the center of the muscle complex is facilitated using real time sonography and computed tomography. A soft guide wire is inserted under image control which serves as the route for final pull through of bowel. The operative technique consists of a subcoccygeal approach to dissect the blind rectal pouch. The separation of the rectum from the fistulous communication followed by pull through of the bowel is performed through the same incision. The skin or the levators in the midline posteriorly are not divided. Postoperative anorectal function as assessed by clinical Wingspread scoring was judged as excellent, good, fair and poor. Older patients were examined for sensations of touch, pain, heat and cold in the circumanal skin and the perineum. Electromyography (EMG) was done to assess preoperative and postoperative integrity of external anal sphincter (EAS).</p> <p>Results</p> <p>The patients were separated in 2 groups. The first group, Group I (n = 10), were newborns in whom SSARP was performed as a primary procedure. The second group, Group II (n = 16), were children who underwent an initial colostomy followed by delayed SSARP. There were no operative complications. The follow up ranged from 4 months to 18 months. Group I patients have symmetric anal contraction to stimulation and strong squeeze on digital rectal examination with an average number of bowel movements per day was 3–5. In group II the rate of excellent and good scores was 81% (13/16). All patients have an appropriate size anus and regular bowel actions. There has been no rectal prolapse, or anal stricture. EAS activity and perineal proprioception were preserved postoperatively. Follow up computed tomogram showed central placement the pull through bowel in between the muscle complex.</p> <p>Conclusion</p> <p>The technique of SSARP allows safe and anatomical reconstruction in a significant proportion of patients with ARM's without the need to divide the levator plate and muscle complex. It preserves all the components contributing to superior faecal continence, and avoids the potential complications associated with the open posterior sagittal approach.</p

Rectum (arrow) is mobilized upwards by clearing the perirectal adhesions so that adequate length is available for pull through without anastomotic tension

<p><b>Copyright information:</b></p><p>Taken from "Sphincter saving anorectoplasty (SSARP) for the reconstruction of Anorectal malformations"</p><p>http://www.biomedcentral.com/1471-2482/7/20</p><p>BMC Surgery 2007;7():20-20.</p><p>Published online 24 Sep 2007</p><p>PMCID:PMC2093923.</p><p></p

Complete separation of the rectum (black arrow) from the fistula (white arrow) continues until the fistula is completely free

<p><b>Copyright information:</b></p><p>Taken from "Sphincter saving anorectoplasty (SSARP) for the reconstruction of Anorectal malformations"</p><p>http://www.biomedcentral.com/1471-2482/7/20</p><p>BMC Surgery 2007;7():20-20.</p><p>Published online 24 Sep 2007</p><p>PMCID:PMC2093923.</p><p></p

The path of guide wire is dilated serially till it accommodates a appropriate sizes Hegar Dilator

<p><b>Copyright information:</b></p><p>Taken from "Sphincter saving anorectoplasty (SSARP) for the reconstruction of Anorectal malformations"</p><p>http://www.biomedcentral.com/1471-2482/7/20</p><p>BMC Surgery 2007;7():20-20.</p><p>Published online 24 Sep 2007</p><p>PMCID:PMC2093923.</p><p></p

The separation of the rectum (black small arrow) and the urethra is started by creating a plane of dissection in the common wall of the fistula (white arrow)

<p><b>Copyright information:</b></p><p>Taken from "Sphincter saving anorectoplasty (SSARP) for the reconstruction of Anorectal malformations"</p><p>http://www.biomedcentral.com/1471-2482/7/20</p><p>BMC Surgery 2007;7():20-20.</p><p>Published online 24 Sep 2007</p><p>PMCID:PMC2093923.</p><p></p

Sonogram showing important anatomical landmarks which guide accurate central placement of guide wire

<p><b>Copyright information:</b></p><p>Taken from "Sphincter saving anorectoplasty (SSARP) for the reconstruction of Anorectal malformations"</p><p>http://www.biomedcentral.com/1471-2482/7/20</p><p>BMC Surgery 2007;7():20-20.</p><p>Published online 24 Sep 2007</p><p>PMCID:PMC2093923.</p><p></p> Points A and B indicate ischial tuborosities. Dashed curved line indicates the medial borders of the levators on both sides. The star in the center corresponds to the position of the anal dimple

Follow up CT scan showing rectum (straight arrow) placed in midline to the muscle complex (block arrows)

<p><b>Copyright information:</b></p><p>Taken from "Sphincter saving anorectoplasty (SSARP) for the reconstruction of Anorectal malformations"</p><p>http://www.biomedcentral.com/1471-2482/7/20</p><p>BMC Surgery 2007;7():20-20.</p><p>Published online 24 Sep 2007</p><p>PMCID:PMC2093923.</p><p></p