Anorectal Malformation general surgery.pptx

GENERAL SURGERY

1. Anorectal malformation Dr Reshma Chandrasekaran DNB General Surgery Resident

2. INTRODUCTION Anorectal malformation is the general term for a variety of diagnoses often referred to as imperforate anus. Patients with this diagnosis do not have a normal anal opening, but instead, a fistulous tract opens onto the perineum anterior to the anal muscle complex or into adjacent anatomical structures. In the male, the fistulous tract can connect to the urinary system and in a female, to the gynecologic structures.

3. embryology THEORY 1: Embryonically the urinary tract, reproductive tract, and gastrointestinal tract form a common channel called a cloaca , which is followed by separation of these structures and the migration of the anorectal septum around the seventh week of gestation . THEORY 2: The rectum migrates towards the perineum during development, and this is abnormal in the formation of anorectal malformations.

4. ANATOMY OF RECTUM AND ANALCANAL

5. Symptoms / signs No visible anus or an anal opening that is not in the normal location Inability to pass stool or constipation Stool that leaks from the vagina or is visible in the urine Urine that comes from the anus An anus that is tighter or more narrow than normal

6. examination For an anus to be normal, it should be in the correct location and the proper size, based on age. The normal size anus of a full-term infant is a 10 to 12 Hegar dilator (an instrument used to size the anus), and the size of a 12-month-old should be about a 15 Hegar dilator. The basis of the correct location is on the anal opening being in the center of the anal muscle complex. The perineum should be thoroughly evaluated taking care to pay attention to features such as the development of the buttocks, the presence of a gluteal fold, and the examination for any type of opening or orifice on the perineum. In female patients with an anorectal malformation, a thorough vaginal exam should also take place, taking care to note the number of openings on the perineum.

7. Less than 0.5 indicates poor continence post op.

8. Treatment of low lying arm OperOperative procedure for the surgical treatment of anal stenosis. A: Martin’s anoplasty; B: Y-V advancement flap; C: V-Y advancement flap; D: Diamond-shaped flap; E: House-shaped flap; F: U-shaped flap; G: Rotational S-flap.

9. Goals of surgery The most important aim of the surgical correct ion is to create a normal anus with anatomic reconstruction. Surgery should help the child to achieve a socially acceptable bowel function and should ensure avoiding fecal incontinence, urinary incontinence or sexual dysfunction. The choices of surgical correction are as follows: a. Primary repair – both boys and girls (3-6) b. Staged repair – usually 3 stages:

10. Staged repair i. Colostomy – most probably high sig moid loop in left iliac fossa. ii. Pull through – Posterior sagittal approach, abdomino-perineal approach, abdominal posterior sagittal approach, laparo scopic approach – in boys; anterior sagittal ap proach , anal transposition, posterior sagittal, abdomino -perineal, abdominal posterior sagit al approach – in girls. ( regular dilatation of new anus after 3 weeks) iii. Colostomy closure. (after 3 months)

11. Indication for colostomy

12. Distal colostogram Water-soluble contrast is used and continued pressure is applied during injection of dye to ensure that the fistula is opacified. Images are obtained under fluoroscopy. The colostogram is obtained in the lateral position, with the femora overlapping as perfectly as possible, to determine the level of the blind end of the rectum and identify the type of ARM.

13. steps Step 1: Placing sutures around fistula Step 2: Sagittal opening in midline Step 3: Dissection fistula/ rectum Step 4: Reconstruction of sphincter complex Step 5: Anoplasty

14. laarp Laparoscopically assisted anorectal pull-through (LAARP) for high anorectal malformations (ARMs) reduces the amount of posterior dissection and avoids dividing and weakening external sphincters required for accurate placement of the bowel into the muscle complex and diminishes perirectal scarring. Repair of associated defects at operation (i.e., hernia, identification and repair of cryptorchid testes) is possible.

15. (a) Slingshot appearance of puborectalis. (b) Laparoscopic backlight as a guide for perineal incision. (c) 10 mm trocar inserted into the peritoneal cavity. (d) Rectal pull-through through 10 mm trocar (a) Port placement. (b) Visualization of anatomy. (c) Subserosal dissection. (d) Creation of tunnel through the puborectalis

16. Post op complication Post-operative complications can include: Superficial and deep wound infection, Dehiscence of the anastomosis, Prolapse of the anoplasty, or stricture of the anoplasty. Recurrent fistulas between the urinary system in males or gynecologic system in females can also occur. These usually occur if the surgical repair is on excessive tension or there is inadequate blood supply to the rectum.

17. Peristeen empties the bowel by introducing water into the bowel using a rectal catheter.

18. Following MACE surgery, the bowel is “flushed” , usually daily, with body temperature water through a catheter inserted into the bowel through the stoma. Each irrigation generally takes 30-60 minutes

19. conclusion Multidisciplinary approach: paediatrician, paediatric surgeon, radiologists, nursing team, physiotherapist, and stoma care nurse etc. Pre operative workup Meticulous surgical technique Post op follow-up

20. Thank you