New developments in anal surgery: Congenital ano-rectal malformations

Abstract

Congenital ano-rectal malformations present with a wide spectrum of severity. Some patients have relatively benign malformations that require a straightforward surgical repair, and the patient has an excellent prognosis in terms of bowel control. Other patients may have far more substantial defects. The surgical repair for these types of malformations is more complex, and the prognosis for urinary and bowel control is variable, primarily depending on the severity of the defect. Through the examination of a large series of patients, we have come to understand far more about the condition known as imperforate anus (IA) than has been understood in the past. Because of the excellent exposure that is achieved with the posterior sagittal approach, a better understanding of the actual anatomy that exists in these patients has been realized. This has led to a new classification system, based on the actual anatomy, with technical and prognostic ramifications. It has become clear that the pressure augmented distal colostogram is the most important test for planning the definitive repair in those patients that cannot undergo primary repair in the newborn period. A push toward newborn primary repair has been seen, and some authors have reported this approach in patients with more complex malformations. The posterior sagittal approach in male patients has been refined, and the vast majority of these patients can now be repaired without a laparotomy. In female patients, those with a vestibular fistula can be repaired in the newborn period without a colostomy, although the repair is technically demanding. By far the most significant technical advance is the development of the maneuver known as total urogenital mobilization. This maneuver, used during the repair of cloacas, has significant decreased the total operative time and postoperative complication rate associated with this operation. Finally, the use of minimally invasive techniques has been applied to these conditions. © 2003 Elsevier Inc. All rights reserved.