The Perineal Body Preserving PSARP (PPP)

For females with anorectal malformation, six anatomic options exist: rectovesibular fistula, rectovaginal fistula, rectoperineal fistula in the center of the perineal body, rectoperineal fistula within the sphincteric complex at its anteriormost extent, anal stenosis, and slightly anteriorly located but otherwise normal anus.

With all anorectal malformations, it is vital to inspect for any associated anomalies.

In females with anorectal malformations, vaginoscopy is performed to look for associated Mullerian anomalies such as vaginal septum, distal vaginal atresia, and a variety of uterine anomalies.

The traditional PSARP is done in prone position with cutting of the perineal body down to the vestibular fistula, including a long posterior sagittal incision from the coccyx down, mobilizing the rectum off the posterior wall of the vagina, repairing the perineal body, completing the anoplasty, and closing the posterior sagittal incision.

An electrical stimulator (the same one used by anesthesia for train of four) can define the extent of the sphincter, but muscle relaxation must be avoided for the stimulator to work well.

The perineal body preserving technique (PPP) does not require a posterior or anterior incision; the entire incision need only be the extent of the sphincter.

In the PPP, retractors can inadvertently split the perineal body; to help avoid this, a suture is placed at the anteriormost extent of the intended anoplasty.

In the PPP, the perineal body is not incised.

The lateral aspects of the rectum are intimately attached to the vaginal wall and must be dissected with great care not to injure the vaginal wall.

A helpful concept is to think of the PPP like a bulbar fistula repair in a male with anorectal malformation.

Placement of multiple sutures across the anterior lip of the rectal wall is a vitally important step because it facilitates lifting the rectal wall up and separating it from the posterior vaginal wall.

The rectum is mobilized and dissected within the whitish fascia that envelops the rectum.

A Hagar dilator in the vagina facilitates dissection of the rectum from the vagina.

The perineal body muscles are sutured together where the fistula used to be, and this will form the sphincter anterior to the new anoplasty.

In the PPP technique, no sutures are needed in the perineal body's skin; the perineal body skin is untouched.

The rectum is split on its anterior and posterior wall, and the anoplasty is completed with 16 absorbable sutures placed full thickness, rectal wall to anal skin.

After completion of the anoplasty, the patient is turned supine, the fistula tissue is excised, and the mucosa of the vestibule is repaired where the fistula had been.