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This chapter describes the posterior sagittal/laparoscopic/surgical procedure for posterior sagittal anorectoplasty (including laparoscopic ligation of __fistula) if anatomically appropriate, as performed by the following approaches: open and laparoscopic. The text includes an introduction that outlines the indications, risks, alternatives, essential steps, needed equipment, and variations in technique for the procedure in question. This is followed by a template operative dictation, which provides the reader with an operative report, such as is found in a patient chart or electronic medical record. A description is provided of the following critical concepts for this procedure: identification of the fistula, marking the limits of the sphincter mechanism, dissection of the fistula/rectum from urethra/prostatic urethra or bladder neck, mobilization of rectum, and performing the anoplasty.

Pull-through procedures involve complete or distal proctectomy with restoration of gastrointestinal continuity at or below the level of the anorectal junction. Examples include coloanal anastomosis, ileal pouch-anal anastomosis, perineal proctectomy, and transanal or transabdominal endorectal pull-through procedures in children for Hirschsprung’s disease or high imperforate anus. Common indications include distal rectal cancer, rectovaginal or rectourethral fistulae, inflammatory bowel disease, and rectal prolapse. Complications of these procedures are diverse, including bleeding, anastomotic leak, chronic anastomotic sinus, anastomotic stricture, and prolapse. Children who had previously undergone a pull-through procedure to treat Hirschsprung’s disease or imperforate anus may suffer from fecal incontinence or constipation with poor emptying of the neorectum. Although pull-through operations may result in a myriad of complications, there are several nonoperative and operative management strategies to not only treat the acute complication but also achieve a functional anastomosis without a permanent stoma. Nonoperative strategies include endoscopic and percutaneous procedures. An expeditious diagnosis and treatment of anastomotic complications may allow for local, less invasive methods to adequately treat the problem, ultimately preventing long-term anastomotic failure. Resection and reanastomosis should be considered the treatment of last resort following a pull-through procedure.

Congenital abnormal fistulas between urethra and anorectum or vagina are usually associated with imperforate anus. Congenital recto or anourethral fistulas without anorectal malformations are extremely rare in males and have been called N-type or H-type fistulas1. In many series, this fistulas are not considered under the types of congenital urethra fistula, because these abnormalities have been included as a subtype of anorectal malformation (ARM), even in cases of normally located anus. There is no general agreement about urethral fistula as an identified anomaly, as it may be considered as a sort of urethral duplication or an associated anomaly with other congenital malformations.

Anorectal malformation is a well-documented spectrum of disorders that has been reported in 1/4000–1/5000 births. The exact etiology is not well understood, and it has been linked to some genetic and familial dissociations. This wide spectrum of congenital disorders ranges from imperforate anus with or without fistulas to the urethra, bladder, or perineum to complex anogenital malformations involving the entire ano-genito-urinary tract. The open posterior sagittal anorectoplasty (PSARP) is the current standard for surgical management of anorectal malformations. Introduction of laparoscopy allowed better visualization of the depth of the infant’s pelvis and safe dissection of high types of anorectal malformations and led to the development of a minimally invasive laparoscopic approach for high imperforate anus, introduced in 2000 by Georgeson et al.

In any age group, creation of an intestinal stoma is a significant event with major physiologic, body image, lifestyle, and psychosocial implications. Management and indications for ostomies in infants and young children are often different than in adolescents and adults. This is a consequence of the differing diagnoses, physiology, size, growth and development issues, complications, and unique patient and parental adjustment concerns.