The anterior sagittal approach for high imperforate anus: A simplification of the mollard approach

Abstract High imperforate anus is a complex anomaly that requires a combination of careful preservation of native structures and precise anatomic reconstruction for optimal results. Previously the authors used an anterior perineal approach derived from the technique described by Mollard, with generally satisfactory results. The present report describes the authors' refinement of the technique to avoid skin flaps and to construct a shorter, more normal anal canal. The perineal approach, via an anterior sagittal incision, usually is combined with a transverse suprapubic laparotomy. The technique includes division of the external sphincter and longitudinal muscle fibers anteriorly, simple dilatation of the puborectalis, and division of the fistula close to the urethra, with preservation of the internal sphincter. The rectal pouch is brought down to the level of the puborectalis, without tapering, and the anoderm is brought up to the level of the rectal pouch to construct a shorter anal canal with a normal anorectal angle. This technique maximally preserves internal sphincter function, preserves specialized anoderm for the anal canal, and avoids extensive pelvic dissection and division of the levator sling. It also facilitates repair in the neonatal period, which may be optimal for long-term continence. The authors have used this technique in five patients, with good anatomic and short-term functional results. The authors believe that the technique provides optimal preservation of native tissues; only minimal destruction and dissection are required for reconstruction.