2025 Pediatric Surgery Update Course - Updates in Colorectal: Debunking Dogma

When dilating a recto-vestibular fistula preoperatively, dilate only to 7 Hegar to decrease potential scarring along the tract for future PSARP.

Preoperative fistula dilation is a controlled tear when the fistula starts as a pinhole, not true stretching; dilate only as big as needed and then leave it alone until definitive repair.

Perineal body-preserving PSARP is basically the same technique one would use for a bulbar fistula but applied to a vestibular fistula.

For perineal body-preserving PSARP, the key is to really clean up the lateral planes before coming around the front, mobilizing the sides and staying on the bowel wall before deciding to come through the common plane.

When starting perineal body-preserving PSARP, it is acceptable to go a little bit into the perineal body on the front and a little bit behind it in the back to make the working incision not the tightest pinhole, while still keeping the perineal body largely intact.

If lost in the anatomy during perineal body-preserving PSARP, it is easy to convert to a standard PSARP by extending the incision.

Preoperative dilations seem to be more tolerated than postoperative dilations; families are worried they will hurt their babies and the repair.

Heineke-Mikulicz stricturoplasty is a minimally invasive surgical backup option for neo-anal stricture if not performing routine postoperative dilations.

Families who are competent with rectal irrigations before Hirschsprung pull-through will be more comfortable performing irrigations after pull-through, which can save the baby's life by treating enterocolitis early.

Families who are really good at irrigations start treatment for enterocolitis before they ever call the surgeon.

Longer aganglionic segments in Hirschsprung disease affect timing of pull-through; patients who cannot be adequately decompressed at home may require earlier intervention to prevent enterocolitis or perforation.

Absent ganglion cells in fistula tissue does not necessarily mean Hirschsprung disease, as fistula tissue is not physiologic tissue.

Complex anorectal malformation patients with chromosomal anomalies who are not responding to laxatives or enemas are worth working up for Hirschsprung disease.