Anorectal malformations affect 1 in 2,500 to 5000 births. There are multiple classifications systems based on anatomy and surgical management. Over the last 2 decades, the posterior sagital anorectalplasty (PSARP) has become the standard surgical approach for most types of imperforate anus. Treatment options for low imperforate anus including rectoperineal and rectovestibular fistula are based on gender, anatomy, fistula location and surgeon's expertise. Surgical options include PSARP, anterior sagital anorectoplasty, cutback anoplasty, and Potts transfer anoplasty. A majority of surgical procedures disrupt the muscular sphincter complex. We present management of low imperforate anus without disruption of the muscular complex.

The patient draped in supine position. Using a nerve stimulator the point of maximal muscle contraction is identified and a cruciate incision is performed for the neo-anus. The fistula is dissected and mobilized away from the vaginal wall for sufficient length. At the cruciate incision careful blunt dissection is performed to tunnel a tract through the muscular complex. Sequential dilation of this tract is performed and the mobilized rectum is pulled through. The perineal body is reconstructed with sutures securing the rectum. The correctly positioned neo-anus is completed by a muco-cutaneous anastomosis.

We have performed this procedure with success in patients with low imperforate anus without significant perioperative morbidity or mortality.

Imperforate anus may be treated with minimal disruption of the sphincter complex. Further study is needed to verify improvement in continence and outcome as compared to other surgical techniques.