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478
Fig. 26.43 Diagram
showing the rectum
dissected and pulled down
enough to resect 5 cm
above the tumor
26 Posterior Sagittal Approach for the Treatment of Other Conditions
Fig. 26.44 Picture of the operative fi eld, showing the
rectum pulled over
Fig. 26.45 Picture of the operative fi eld. The rectum has
been opened to show the tumor
26.10 Presacral Masses
479
rectum mobilized, sutured with two layers of
interrupted long-term absorbable sutures to the
lower rectum above the pectinate line.
Figure 26.44 shows a full mobilization of the
rectum, immediately prior to the resection.
Figure 26.45 shows the operative fi eld; the rec-
tum has been opened to show the location of the
tumor and to be sure that we leave a 5-cm margin before we suture the upper rectum to the
lower rectum. Figure 26.46 shows the operation
completed. The rectum has been mobilized and
sutured to the lower rectum.
Fig. 26.46 Diagram showing the operation completed.
Anastomosis done 2 cm above the pectinate line
26.10 Presacral Masses
Presacral masses in association with anorectal
malformation were discussed in the chapter of
perineal fi stula.
There are, however, cases of presacral masses
with or without sacral defects, without anorectal
malformation.
Our series of presacral masses includes over
50 cases, mainly dermoid, teratomas, lipomas,
and anterior meningocele, but also includes one
schwannoma and two malignant tumors. That is
another reason why all the presacral masses must
be resected. Patients with presacral masses and
no anorectal malformations have mainly cystic
teratomas. Figure 26.47 shows the MRI of the
pelvis of an adult patient with giant cystic presacral teratomas without a sacral defect. The presence of presacral masses without sacral defect
has a much better functional prognosis in terms
of bowel and urinary function.
There are many other patients that are born
with presacral masses without anorectal malformation. These types of cases are more diffi cult to
detect. A typical example is a patient that suffers
from, what the doctors believed, an infected pilonidal sinus. The patient is operated several times,
only to fi nd that the abscess and drainage keep
recurring. Under such circumstances, it is
recommended to order an MRI of the pelvis,
a b
Fig. 26.47 MRI of a patient with giant cystic mature teratomas, without a sacral defect. ( a ) Transverse section.
( b ) Sagittal view
480
26 Posterior Sagittal Approach for the Treatment of Other Conditions
Fig. 26.48 Infected presacral dermoid, misdiagnosed as
a recurrent pilonidal cyst. The patient underwent seven
previous failed operations
had a very large presacral mass that had become
chronically infected.
Another one of our patients, a 19-year-old
girl, suffered from constipation of unknown origin for her entire life. She developed an abscess
in the area of the sacrum, as well as manifestations of meningitis and sepsis. She became
extremely ill and was admitted to the hospital.
The abscess was drained, and the sepsis and meningitis were controlled; the patient developed as
sequelae a chronic draining sinus in the area of
the coccyx. Figure 26.49 shows the external
appearance of this patient. Figure 26.50 shows
the same area, immediately after the resection of
a very large presacral infected dermoid. The
x-ray fi lm showed a hemisacrum. Patients who
suffer from idiopathic constipation should have,
as part of their evaluation, an x-ray fi lm of the
sacrum, as well as an MRI of the spine and cord,
to rule out the presence of presacral masses.
Table III shows our series of presacral masses by
histologic diagnosis, with and without association with anorectal malformation and with and
without association of sacral abnormality.
Fig. 26.49 Chronic draining sinus in the sacral area, the
patient had an infected presacral dermoid
Fig. 26.50 External aspect immediately after the
operation
which may disclose the presence of a teratoma or
dermoid that becomes infected and drains in the
subcoccygeal area. Figure 26.48 shows a 6-year-
old girl that had seven previous operations under
the misdiagnosis of a pilonidal sinus; actually she
26.11 Surgical Technique
Most presacral masses are resectable using only
the posterior sagittal approach without an abdominal intervention. We are not including in this discussion the cases of neonatal sacrococcygeal
teratomas, which represent, we believe, a different
entity, with special characteristics and important
technical considerations. The posterior sagittal
incision is done, as described multiple times in this
textbook. It is very important for the surgeon to
have a very precise anatomic diagnosis of the
mass, with emphasis in the location, in terms of
distance between the coccyx and the mass. Using a
posterior sagittal approach, we can usually reach
up to the level of sacral vertebra 2 or 3; above that,
it would represent a serious technical challenge.
The incision involves exactly the midline and
divides the skin, the subcutaneous tissue, and the
entire sphincter mechanism. The MRI study
should alert us as to what we are going to fi nd after
we divide the entire sphincter mechanism
below the coccyx. If the mass is located above the
26.12 Posterior Sagittal Approach, Its Application in Cases with Hirschsprung’s Disease
481
Fig. 26.51 Intraoperative picture of the resection of a
retrorectal mass
coccyx, then we will identify, right away, the posterior rectal wall, and dissecting on top of the rectal
wall, we will be able to fi nd the mass. On the other
hand, sometimes the mass is attached to the posterior rectal wall below the coccyx, and therefore,
we should look and expect the mass to be found as
soon as we divide the sphincter mechanism.
Figure
26.51 shows the operative fi eld of one of
these operations, where the mass can be seen in the
deepest portion of the incision. We usually place
several silk stitches in the mass in order to apply
uniform traction to facilitate the dissection. We
must be aware of the fact that the mass and the
posterior rectal wall are intimately attached; basically we have to shave the posterior rectal wall to
separate the mass. In those congenital cases, in
which the mass has been compressing the rectum
in utero, the resection of the mass is sometimes not
enough to deal with the problem, due to a stricture
of the rectum. That stricture is fi brotic and should
not be expected that it would regain a normal
caliber after the mass has been resected. Our
experience shows that it is necessary to resect the
narrow portion of the rectum and pull down the
healthy- looking bowel. Sometimes there is a very
giant dilated upper rectum that must be tapered in
order to pull it down. Several patients came to us
after they underwent the resection of the mass;
they had been subjected to multiple anorectal dilatations, with the expectation that the narrow portion of the rectum would improve which actually
does not happen. Therefore, from day one, we suggest to resect that narrow portion of the rectum.
In those cases, in which the surgeon is able to
make the diagnosis of anterior meningocele
component of the mass, the patient should be
seen by a pediatric neurosurgeon with experience
in these kinds of problems. When the anterior
meningocele is very small, sometimes we can
simply respect it, knowing that it is there, and
leave it in place. However, some neurosurgeons
prefer to approach the patient from behind,
through a laminectomy to close the communication of the dura with the presacral mass. In the
second stage, the surgeon may resect the posterior rectal component, of the meningocele, without being concerned about injuring the dura.
Other neurosurgeons prefer to be present during
the posterior sagittal resection of the mass and to
close directly the dural defect. Usually, in addition to the closure with nonabsorbable sutures, a
patch of fat, muscle, or sometimes cartilage is
used to reinforce the defect. We have never seen
a case of chronic drainage of cerebrospinal fl uid
consecutive to one of these operations.
26.12 Posterior Sagittal Approach,
Its Application in Cases
with Hirschsprung’s Disease
In the chapter corresponding to Hirschsprung’s
disease, we briefl y mentioned cases of reoperations that may represent a very serious surgical
technical challenge, due to the fact that the patient
suffered from dehiscence, infection, abscesses,
and fi stulas that provoked a very signifi cant
amount of fi brosis in the pelvis. These patients are
particularly diffi cult to treat using a traditional
transanal or abdominal approach. When confronted with that type of case, the surgeon must
482
ab
26 Posterior Sagittal Approach for the Treatment of Other Conditions
Fig. 26.52 Diagram showing a sagittal view of the pelvis
of a girl who underwent a failed attempted repair for
Hirschsprung’s. There was a dehiscence of the anastomo-
consider the possibility of approaching the patient
posterior sagittally. These patients are frequently
referred to us with a patent anus, but an atretic rectum as a consequence of dehiscence of the pullthrough. The area of fi brosis that produced the
acquired atresia or stricture of the rectum is located
in a place diffi cult to access in the pelvis. Trying to
resect the lower rectum, preserving the anal canal,
as well as pulling normal bowel down through a
“cement type” of pelvis may prove to be extremely
diffi cult. Figure
26.52a shows a diagram with a
sagittal view of a female patient who suffered from
this kind of problem. There was a dehiscence of
the anastomosis, producing a local abscess, severe
scarring, and fi brosis. The reoperation for these
complications should be done not before 6 months
after the event. Figure 26.52b is a diagram of the
completed repair. A distal colostogram is performed in order to see the precise location of the
normal- looking upper bowel, as well as injection
of contrast material from below, in order to measure the gap between the proximal and distal
bowel. A rectal examination allows the surgeon to
realize that there is a lot of scar and therefore very
diffi cult to attempt a traditional transanal or
abdominoperineal approach. Under those circum-
sis, leaving the patient with an acquired rectal atresia and
severe pelvic fi brosis. ( a ) Preoperative diagram. ( b )
Postoperative diagram
stances, the posterior sagittal approach represents
a viable alternative. Something similar happens in
patients who underwent a Soave type of pullthrough, and, for unexplained reasons, the surgeons left pieces of bowel mucosa attached to the
muscular cuff; those islets of mucosa produce
mucus, abscess, and fi stula formation and are
extremely diffi cult to fi nd in a reoperation, particularly when trying to do it with a traditional
approach. Again, the posterior sagittal approach
gives much better exposure and more chances to
fi nd those remnants of mucosa. We have found
trapped pieces of bowel left in the pelvis producing mucous and multiple fi stulas, sometimes
draining into the perineum, sometimes into the
vagina or through the urinary tract.
26.13 Vaginal Atresia with Normal Rectum
Patients suffering from vaginal atresia have a
dilated, blind vagina located at different levels
sometimes compressing the trigone of the bladder. Depending on the specifi c distance between
the blind lower part of the vagina and the
26.13 Vaginal Atresia with Normal Rectum
483
perineum, the surgeon must select the best possible approach to mobilize the vagina down. If
the vagina is considered not reachable through
the perineum, one alternative that we have used is
exploring the space between the urethra and rectum, trying to reach as high as possible, provided
we feel safe and confi dent in not producing injury
of the rectum or urethra. Once we have reached
from below the point in which we feel it is not
safe to continue, then the vagina can be mobilized through the abdomen with a laparotomy or
laparoscopy. In the event of fi nding the blind
vagina during the exploration between the urethra and rectum, but the mobilization becomes
technically diffi cult, in a patient that has been
subjected to a strict bowel preparation prior to the
procedure, we can expand the incision transanorectally, as demonstrated in cases of urogenital sinus with normal rectum. Provided the
reconstruction of the rectum is performed meticulously, as we previously mentioned, the patients
recover very well, even without the opening of a
colostomy. Figure 26.53a–f shows images related
with one specifi c patient who came to our clinic
with a very dilated blind vagina (hematocolpos
and hematometra). With the bowel completely
clean in order to have access to trans-anorectal
approach, if necessary, we approached the patient
through the perineum, and we were fortunate
enough to fi nd the vagina and were able to mobilize the vagina down enough to reach the labia,
without having to divide the rectum. However,
we can easily divide the rectum, if necessary, if
the procedure becomes technically demanding.
Figure 26.53a shows the preoperative aspect of
the introitus of this patient that only shows the
urethral opening. There is no vaginal opening.
Figure 26.53b shows the MRI of this patient.
Figure 26.53c, d shows the appearance of the
fi eld during the surgical exploration, looking for
the vagina. Figure 26.53e shows that the vagina
has been mobilized, and Fig. 26.53f shows that
the vaginal opening has been successfully
created.
Fig. 26.53 Vaginal atresia, hematocolpos, and hemato-
metra. ( a ) Introitus showing only the urethral opening. ( b )
MRI study showing the giant vagina. ( c ) Surgical explora-
tion between the urethra and the rectum. Silk sutures
ab
applied on the vagina. ( d ) Vagina open. Observe old blood
coming out. ( e ) Vaginal fully mobilized. ( f ) Finished
operation
484
26 Posterior Sagittal Approach for the Treatment of Other Conditions
cd
ef
Fig. 26.53 (continued)
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Miscellaneous Conditions
2 7
27.1 Part I: Perianal Abscess and Fistula
27.1.1 Defi nition
Perianal fi stula is a fairly common condition in
male infants. It consists in the presence of a tract
that runs from one of the anorectal crypts toward
the perianal skin (Figs. 27.1 and 27.2 ). This fi s-
tula occurs as a consequence of an abscess previously formed in the perianal area. We do not
know precisely the incidence of this condition. It
is extremely unusual to see this condition in
female patients, as well as in older children. In
pediatrics, this condition has very signifi cant
differences when compared with perianal and
perirectal fi stulas in adults [ 1 – 3 ]. It is important
to recognize these differences because of their
therapeutic implications.
Perianal and perirectal abscesses and fi stula
are fairly common in the adult population, but it
occurs in forms and variants more severe and
serious than in pediatrics [ 1 – 3 ]. The recom-
mended treatments in adults also vary, depending
on the type of fi stula (transsphincteric, translevator, intrasphincteric). In pediatrics, we only see a
benign form in babies (mainly males), and that is
the type that we will discuss here.
Fig. 27.2 Perianal fi stula. Arrow shows the point of the
Fig. 27.1 Perianal abscess
A. Peña, A. Bischoff, Surgical Treatment of Colorectal Problems in Children,
DOI 10.1007/978-3-319-14989-9_27, © Springer International Publishing Switzerland 2015
future fi stula
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