Atresia Ani pada anak

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norectalMalformations
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1710, Littre's suggested performing an inguinalcolostomy for imperforate anus

1783, Dubois acted and other surgeons followed suit, but

almost all infants died, so colostomy remained unpopular

and only a procedure of last resortIn 1787, Bell suggested using a midline perineal incision

to find the bowel

1826 Dieffenbach described anal transposition

1835 Amussat did mobilization of the bowel through a

perineal incision with suturing of it to the skin and this

technique gained rapid acceptance. Strictures were less

common than was observed with earlier procedures

History


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1856 Chassaignac used a probe through a stoma to

guide the perineal dissection1872 Leisrink, McLeod (1880), and Hadra (1884)recommended opening the peritoneum if the bowel wasnot encountered from below

1930 Imaging to delineate the abnormality was firstadvocated by Wangensteen and Rice

1948-1949 Single-stage abdominoperineal proceduresbecame widely used

1953 Stephens emphasized preservation of thepuborectalis muscle (remember Cook from 1676?)

This surgery and its modifications were the standardapproach until 1980

History


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Males

Perineal fistula No ColostomyRectourethral fistula

Bulbar

Prostatic

Rectovesical fistula (bladder neck) Colostomy

Imperforate anus without fistulaRectal atresia

Females

Perineal fistula No Colostomy

Vestibular fistulaPersistent cloaca

3 cm common channel

Imporforate anus without fistula

Rectal atresia

Classification of Anorectal Malformation by Pea


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Bowel control is the main concern for thesurgeon correcting these anomalies. Urinary

control and sexual function must also be

considered.

Associated problems, such as a poorly

developed sacrum, nerve supply, and spinal cord

likely contribute to an inability to achievecontinence


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Incidence: 1 in 5000 live births.

Most common in females is a rectovestibular

fistula

50% of all patients with anorectal

malformations have an associated urogenitalanomaly

The relationship of the distal rectum to thepuborectalis muscle divides the imperforate

anus malformations into high (supralevator)

and low (infralevator) malformations


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Early treatment for neonates born with an anorectal

anomaly is crucial.

During the first 24-48 hours of life, answer the following

2 questions:

1. Are any associated anomalies present that threaten the

baby's life and need to be addressed immediately?

2. Should the infant undergo a primary procedure with noprotective colostomy or a protective colostomy with a

definitive repair at a later date?


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Trying to determine the location of the distal rectum

before 16 hours of life is senseless

because of the contracted state

of the funnellike sphincter mechanism.


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10

FEMALE


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11

MALE


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CLINIC L EX MIN TION Perineal inspection may show a normal urethra,

normal vagina, and another orifice that is therectal fistula

Meconium beneath the membranous coveringtypical of a low lesion

A flat or rockerbottom perineum indicates poorsphincter or levator muscle development typical of

a high anomaly Female malformations, 95% are of the low variety

Most male anomalies are high


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Newborn boy with imperforateanus.

Newborn girl with imperforate

anus.
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Imperforate anus and rectovestibular fistula in a newborn.
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Newborn with imperforate anus and a rectoperineal fistula.


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Newborn with imperforate anus and a bucket-handle malformation

(usually associated with a rectoperineal fistula).


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CLINICAL EXAMINATION (CLOACA)

The presence of a single perineal orifice in a

patient is clinical evidence of persistent cloaca

Patients with these anomalies also have small

genitalia

examination of the abdomen may reveal an

abdominal mass that likely represents a distended

vagina (hydrocolpos), which is present in 50% ofpatients with persistent cloaca


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CLOACA


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IM GING STUDIES

In the newborn period

Plain radiography ( spina bifida,

hemivertebrae, hemisacrum )

Crosstable lateral radiography

Ultrasonography ( urologicanomalies, distended vagina,

spinal anomalies)


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Crosstable lateral radiograph of a patient in

which the air column in the distal rectum can

be observed close to the perineal skin.
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AFTER THE NEWBORN PERIOD :

DISTAL COLOSTOGRAPHY

demonstrate the rectourinary communication

and determine the rectum's true height

In most cases of femaleanorectal

malformations, except for persistent cloaca,distal colostography is not necessary

because the fistula is evident clinically


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DISTAL COLOSTOGRAM
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Distal colostogramof apatient with imperforate

anus and a rectourethral

fistula.
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SSOCI TED M LFORM TIONSGENITOURIN RY

Absent, dysplastic, or horseshoekidneys

Vesicoureteral reflux

Hydronephrosis

Hypospadias


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SKELETAL SYSTEM

Partial or complete lumbosacral agenesis

Hemivertebrae

Agenesis of thoracic vertebrae

Scoliosis

Hemisacrum or scimitar sacrum

Asymmetric sacrum

Agenesis of the coccyx


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SPINAL ANOMALIES

Dural sac stenosis

Narrow spinal canal

Myelomeningocele, meningocele

Intraspinal teratoma

Neurogenic bladder


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SURGICAL MANAGEMENT

Initial : Colostomy or Anoplasty

Transversum colon

Descending colon (

Recommended )

Definitive : PSARP


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COLOSTOMY


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PSARP

POSITION


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colostomy with dividedstomas, the proximal

stoma in the distal

descending colon.

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