Posterior sagittal approach for treatment of presacral masses in infancy

 There are very few reports on the surgical management of presacral masses (PSM) via a posterior sagittal (PS) approach. Between 1994 and 2000, we followed five girls who had been operated upon for PSMs via a PS approach. The mean age was 28.8 ± 16.6 months (6–48 months). The mean follow-up was 3 ± 1.6 years (1–5 years). Although two patients had yolk-sac tumors, all patients are still alive. We believe that this is a safe and satisfactory method for resection of PSMs. Accepted: 15 December 2000     

Posterior sagittal rectoplasty for rectal atresia: a definitive approach

Two infants with rectal atresia were successfully treated by end-to-end anastomosis via a posterior sagittal approach with a covering colostomy. The first child had previously undergone numerous local procedures in an attempt to correct the anomaly.     

Posterior sagittal approach for reconstruction of an unusual type of cloacal anomaly

Posterior sagittal anorectoplasty is a popular procedure for treatment of high anorectal malformations. A female infant underwent posterior sagittal anorectovaginourethroplasty for treatment of an unusual type of cloacal anomaly associated with three fistulas: a high and a low rectovaginal fistula, and a high urethrovaginal fistula. A satisfactory anatomic and functional result was obtained. Offprint requests to: S.-Y. Yoo     

Laparoscopic assisted endorectal pull-through with posterior sagittal approach to the repair of postoperative rectourethral and rectovaginal fistula

Rectourethral or rectovaginal fistula is a troublesome complication after anorectal surgery. The pelvic and perineal dissection may be difficult because of severe fibrosis adhesion around the fistula. The authors applied a novel technique: a combined laparoscopic assisted abdominal and posterior sagittal approach (PSA) to perform the redo surgery. Three boys and two girls (3–13 years old): case 1 had rectovaginal fistula after rectal dialation and modified Swenson’s procedure; case 2 had rectovestibular fistula after twice perineal anorectoplasty; case 3 had rectourethral fistula after twice anorectoplasty; case 4 was imperforate anus with Hirschsprung’s disease and rectourethral fistula that had been misdiagnosed; case 5 had rectourethral fistula after abdominoperineoanoplasty and Mollard procedure and posterior sagittal anorectoplasty. Laparoscopic assisted abdominal dissection was done first to mobilize the colon as far as the mid pelvis, and the normal colon was marked with a suture. The lower pelvic dissection was performed through the posterior sagittal route, the proximal rectum was mobilized and servered, the distal rectum was left undisected, endorectal mucosectomy with electric ablation was performed, then the fistula was closed from inside the rectum, and the stump of the colon was pulled through the rectum, the stump and the dentate line were anastomosed extraanally. Colostomy was done in case 2 and case 5. The postoperative follow-up showed no recurrent fistula, and all patients had attained normal voluntary bowel actions, but one child had infrequent minor soiling. Laparoscopic assisted endorectal pull-through of the intact colon can offer precise dissection, minimal abdominal injure, and spare troublesome mobilization of the fistula, and can prevent the recurrent of fistula. Posterior sagittal approach provides a direct repair of the fistula and anastomosis.     

Posterior sagittal transanorectal approach in patients with ambiguous genitalia: report of eight cases

The posterior sagittal transanorectal approach was used for reconstruction of the female genitalia (vaginoplasty) in eight girls with urogenital sinus, high vaginal implantation, and normal rectum, in all cases with a protective sigmoidostomy. These eight patients included four female and four male pseudohermaphrodites. They remain fecally continent, but only seven have urinary continence. One girl has a neuropathic bladder: umbilical discomfort during abdominal straining is present in one patient. One girl married and demonstrated satisfactory sexual intercourse. All patients are alive and healthy, physically and mentally. The transanorectal approach allows separation of the vagina from the urethra and bladder, provides good vaginal mobilization down to the perineum, avoids the utilization of perineal skin flaps and sometimes a laparotomy, and preserves defecation and urinary control. The cosmetic appearance of the genitalia seems to be better than that achieved in the past with other techniques. Accepted: 6 August 1998     

Rectovestibular fistula with vaginal malformations

Anorectal malformations are associated with other anomalies among which vaginal malformations are occasionally encountered and may go unnoticed by the primary physician. Between January 1998 and December 2003, 563 cases of anorectal malformations were managed in Pediatric Surgery Department, Chittagong Medical College & Hospital, Chittagong, Bangladesh. Among these, five cases of rectovestibular fistula were associated with vaginal malformations. In this retrospective study age, physical findings, operative findings and procedures, outcome of operation and postoperative follow-up were evaluated. Mean age at presentation was 8.67 years (range 2 months to 17 years). All cases referred as rectovaginal fistula and vaginal anomalies (atresia to agenesis) were detected after thorough examination. Initial pelvic colostomy was done in all patients. Cases 1, 3 and 4 had distal vaginal agenesis and underwent posterior sagittal anorectovaginoplasty. In case 5, atretic vaginal duplication was found with didelphic hypoplastic uterus and absent left kidney. Case 2 (vaginal atresia) operated elsewhere is waiting for definitive surgery. Colostomy closure was done in four cases. The third patient had already married and conceived. Bowel habits are regular in all except the second patient. In females, a thorough understanding of anorectal malformations is necessary to identify the association with vaginal anomalies and awareness of this association will lead to earlier diagnosis and appropriate operative measures.