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Anal Anatomy
Embryology of the imperforate anus
Definition
Incidence
Classification
Approach
Prognosis
Photos!!☺☼☻
Anal Anatomy
Anorectal
The cloaca
malformations
(which is a common chamber into the hindgut and allantois)
Separated into:
post-allantoic gut
The bladder (rectum)
Proctadeum
Downward growth (epiplastic bud)
of a septum
or vagina (rare)
3)Stenosed anus
i.e. microscopic anus
There is a minute opening that can be seen if examined
carefuly
4)Membranous stenosis
Rare
Anus is normally sited
covered with a thin membrane that bulges
with retained meconium
Could be associated with:
a fistulas connection between the blind
rectal stump and the bladder
or other pelvic structures abnormalitie
1)Anorectal agenesis
Rare
Blind rectal pouch
lies just above the pelvic floor
In males
anterior aspect attached to the bladder
& often there is a rectovesical fistula or
rectourethral fistula (manifested by passage of gas or meconium in the
urine) or
perineal fistula
In♀ fistula to the posterior fornix >> rectovestibular (or
rectovaginal)
low RVF easy to correct
postop. Function is good
high RVF difficult to correct
postop function is poor
2)Rectal atresia
Rare
Anal canal is normal but ends blindly at the level of
pelvic floor & the rectum also ends blindly above the
pelvic floor without a fistulas opening.
3)cloaca
Occurs only in ♀
Bowel, urinary & genital tracts all open into a
common wide cavity
Commonly associated with other developmental
abnormalities e.g. tracheoesophagial fistula
Approach
History >>> the systems involved
Examination >>> DDx
Investigation >>> Dx
Management
History
Failure to pass meconium within the 1st 24 hours of
life.
Examination
Low ?
•Bucket handle defect
When to be done?
it may be necessary to wait until the baby is 24 hrs old before rectal gas
appears
Metal button
PC line
3)US:
To evaluate the lesion type
4)MRI:
If we suspected complex malformation
5)Micturating cystourethrogram:
By injecting a dye in the urethra
Treatment of Low abnormalities:
1)Covered anus:
The track should be opened by scissors
Followed by routine dilatation of the anus
2)Ectopic anus:
Plastic “cut-back” operation
3)Stenosed anus:
Regular dilatation
Treatment of High abnormalities:
Very difficult problem & each case must be considered on its merits
The possibilities are:
Two-stage operation:
1st stage
laparotomy
Division of rectourethral fistula
Transverse colostomy
2nd stage
rectal “pull-through” operation
One-stage operation:
Cont. Treatment of High abnormalities:
It involves:
• Stimulation of muscles to demonstrate the midline and sphincter
• Posterior sagittal incision - length depends on severity of abnormality
and required extent of dissection
• Rectum identified. Abdominal approach may be required in addition in
10% of males and 40% of cloacae
• Rectum dissected
• Separation from genitourinary tract
• Repositioning the neoanus within the sphincteric mechanism
Position for PSARP
Incision in PSARP
Posterior sagittal repair of a rectovestibular fistula .
Prognosis
In high % of cases, imperforate anus is associated with
other congenital abnormalities especially of the
urinary organs & nearly 50% of deaths in cases of
imperforate anus are due to other malformations
IN Summary
1 common single opening in girls>>> Cloaca
2 openings >>> anorectal agenesis with
rectovaginal fistula
3 openings >>> ectopic anus, stenosed anus,
membranous anus, rectal atresia or even normal
anus!!!
The most important investigation is the
invertogram
It is very important to rule out other anomalies
The best & the newest operation is PSARP
Cloaca
Anorectal agenesis and rectovestibular fistula.
Anourethral fistula
imperforate anus and a rectoperineal fistula .
imperforate anus and a bucket-handle malformation
Covered anus
hank you!!
References:
Bailey & Love’s short practice of surgery (24th edition)
The mcinatti children’s hospital medical center (2007)
University of Michigan, Section of Pediatric Surgery
Clinical picture from Emedicine website & Cinncinatti
CHMC.