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Open Access Highly Accessed Technical advance

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

Akshay Pratap1*, Awadhesh Tiwari2, Anand Kumar1, Shailesh Adhikary1, Satyendra Narayan Singh3, Bishnu Hari Paudel4, Rajiv Bartaula1 and Brijesh Mishra1

Author Affiliations

1 Division of Pediatric Surgery, Department of Surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal

2 Department of Radiology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal

3 Department of Anesthesia, B.P. Koirala Institute of Health Sciences, Dharan, Nepal

4 Department of Physiology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal

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BMC Surgery 2007, 7:20  doi:10.1186/1471-2482-7-20

Published: 24 September 2007

Abstract

Background

This report describes a new technique of sphincter saving anorectoplasty (SSARP) for the repair of anorectal malformations (ARM).

Methods

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).

Results

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.

Conclusion

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.