A Delayed Repair of an Iatrogenic Imperforate Anus

[Tom]

Note that the subject in this example is black. Look at that
repeatedly damaged rectum and anus.

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Deeba S and Khoury G*

Clinical Professor of Surgery, American University of Beirut,
Lebanon

*Corresponding author: Ghattas KHOURY, MD, FRCS.FACS, Clinical
Professor of Surgery, American University of Beirut, Lebanon,
Email: gkho...@hotmail.com

Received: July 09, 2014; Accepted: July 14, 2014; Published:
July 18, 2014

In this editorial we report a case of delayed anal
reconstruction. This is a 30 year old male that was injured by
shrapnel from a blast injury in very close proximity about six
months prior to his presentation. The shrapnel entered in his
buttock and avulsed his rectum and anus causing excessive
hemorrhage. At that time, he was managed in a field hospital by
a laparotomy and a colostomy for diversion along with complete
primary closure of his anus for control of bleeding. He
recovered and came to our service for reconstruction (Figure 1).

Figure 1 :Closed off and healed anal verge within black ellipse.

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An MRI of pelvis was ordered to assess the musculature of the
pelvic floor and anal sphincter apparatus. It visualized a
distal rectal stump, but the anus was not well seen. The levator
ani muscles were atrophic but present. The rectal lumen is well
visualized till approximately 2 cm below the coccygeal tip
distally. The external sphincter is most likely present but the
internal sphincter integrity could not be determined on MRI due
to artifact from in situ shrapnel that obscured the anus and
anorectal junction (Figure 2). On exam when you ask the patient
to constrict his anal muscles, a shadow of a moving sphincter
can be seen in the perianal subcutaneous skin that is now closed
off and scarred.

Figure 2 :MRI scan of pelvis showing atrophic levator muscles
within ellipse and present sphincter at tip of white line.

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In the lithotomy position and under general anesthesia, he
underwent exploration of his perineum. The healed closed anal
verge was opened and dissection carried out until the distal
rectal stump was identified along with the external sphincter
and levator ani muscles. A pull down Duhamel type hand sewn
rectoanal anastomosis was performed along with a
sphincteroplasty to reconstruct the anus and achieve continuity.
A rectal tube was left in the repair to avoid strictures (Figure
3 & 4).

Figure 3 :Anal reconstruction with Hagar dilator in distal
rectum and the external sphincter muscle shown at tip of lines.

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Figure 4 :Rectal tube left in situ at the end of reconstruction.

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Figure 5 :Preoperative Hagar dilator in anus before closure of
colostomy.

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