DESCRIPTION • Pena procedure • performed in the prone jackknife position. If the fistula is high, it occasionally will be necessary to turn the patient over for abdominal mobilization of the sigmoid colon. SURGICAL APPROACH • Imperforate anus anomalies are classified as high or low, depending on whether the distal rectum ends above or below the levator muscle • If the fistula terminates on the perineum, it is called a “perineal fistula”or “anterior anus.” • The operation is then performed according to the estimated site of the fistula. Low lesions are dilated or repaired; high lesions are treated with a divided RLQ or loop colostomy Anesthetic Consideration • Pre-operative - Children with rectal or anal agenesis without fistula will have had colostomies in newborn period. • Intra-operative - Combined epidural/GETA, warm OR to 75°–80°F; heating pad on OR table - Induction : Mask induction - Maintenance : Low-dose volatile agent and air/O2 with muscle relaxation for majority of cases. • Post-operative - Pain score : 6-7