Response to: Sparing the Perineal Body, A Modification of the Posterior Sagittal Anorectoplasty (PSARP) for Anorectal Malformations with Rectovestibular Fistulae

Sparing the Perineal Body: A Modification of the Posterior Sagittal Anorectoplasty for Anorectal Malformations with Rectovestibular Fistulae

Sparing the Perineal Body in the Vestibular Fistula

Thank you so much for your letter regarding our recent publication, “Sparing the Perineal Body, A Modification of the Posterior Sagittal Anorectoplasty (PSARP) for Anorectal Malformations with Rectovestibular Fistulae.”[1] We very much appreciate your bringing your previous work to our attention, and are sorry to have not acknowledged it. There are now three articles on this topic of minimizing the disruption of the perineal body in patients with rectovestibular fistulas.[1] [2] [3] We do want to highlight the difference with our work by pointing out that Upadhyaya et al in 2008[2] first described sparing the perineal body in 40 patients with rectovestibular fistula, but utilized a full posterior sagittal incision extending to the tip of the coccyx. Ostertag-Hill et al also similarly avoided an incision through the perineal body in 6 patients but used a longer posterior sagittal incision extending beyond the muscle complex. In our approach, we reaffirm these principles and demonstrate a technique in which the sphincter complex is precisely identified, and then the entire procedure can be accomplished through an incision that is limited to only the length of the sphincter complex itself. All three of these publications show the significant advantage to avoiding any perineal body incision, hopefully eliminating the main and most feared complication following a rectovestibular repair—dehiscence of the perineal body. There are key technical implications of minimizing the exposure the traditional PSARP afforded.[4] The deeper dissection of the distal fistula using our technique's smaller incision is challenging, but with good exposure, using the Lonestar pins, it is very reproducible. The distal rectum must still be adequately mobilized so that there is no tension on the anoplasty, and vital to this dissection is reaching the areolar plan that is at the location of the full separation of anterior rectal wall from posterior vaginal wall. The goal of each of these publications is to minimize complications while ensuring an excellent anatomic reconstruction.

Publication History

Received: 19 May 2023

Accepted: 26 May 2023

Article published online:
06 July 2023

• References

• 1 Badillo A, Tiusaba L, Jacobs SE. et al. Sparing the perineal body: a modification of the posterior sagittal anorectoplasty for anorectal malformations with rectovestibular fistulae. Eur J Pediatr Surg 2023; DOI: 10.1055/a-1976-3611.
• 2 Upadhyaya VD, Gangopadhyay AN, Pandey A. et al. Single-stage repair for rectovestibular fistula without opening the fourchette. J Pediatr Surg 2008; 43 (04) 775-779
• 3 Ostertag-Hill CA, Nandivada P, Dickie BH. Saving the perineal body-a modification of the posterior sagittal anorectoplasty. Pediatr Surg Int 2023; 39 (01) 71
• 4 deVries PA, Peña A. Posterior sagittal anorectoplasty. J Pediatr Surg 1982; 17 (05) 638-643