Dhanya VJ, Assistant Professor,SUM nursing college

1. DHANYA VJ
ASSISTANT PROFESSOR
CHILD HEALTH NURSING
SUM NURSING COLLEGE

2.  Anorectal malformations are defined
as an arrest of rectal descent resulting
in absence of an anal opening and
occur during the 4th -16th week of
gestation.

3.  worldwide- 1 in 5000 live births
 genetic predisposition in certain families
 slight male preponderance
 common defect in females is recto vestibular
fistula
 Males- recto urethral fistula
 association with certain syndromes

4.  unknown
 associated with several other congenital
anomalies of the urinary tract, rectal
atresia and intestines.

5.  The hind gut forms and extends into the tail fold in the
2nd week of gestation
 At about 13 day, a ventral diverticulum, the allentois or
primitive bladder forms
 The junction of allentois and hindgut becomes the
cloaca into which the genital, urinary and intestinal
tubes empty
 This is covered by a cloacal membrane

6.  The urorectal septum descends to divide the common
channel into by forming the lateral ridges, which
grows in and fuse by 7th week.
 Opening of posterior portion of membrane occurs in
the 8th week
 Failures in any of these steps lead to anorectal
malformations.

7.  Stenosis of the anus
 Anal membrane atresia
 Anal agencies
 Rectal atresia

8.  Narrowing of the anus at levels 1 to 4cm
above the anus.

10.  Present with only anal dimple
 In female
 Imperforate anus type 3 with associated fistula
 Low rectovaginal fistula
 High rectovaginal fistula
 Recto peritoneal fistula
TYPES

11. Recto vesical
Recto urethral
Recto peritoneal

12. Anus connected with lower part of
the vagina

13.  Anus communicate with upper part
of the vagina

14.  Anus connect with peritoneum

15. Rectum communicate with
bladder
The sphincter mechanism is
frequently deformed and often
absent. The perineum looks flat

16.  Rectum communicate with urethra
 The sphincter mechanism usually is
satisfactory; a few patients have
poor perineal muscles and a flat-
looking perineum

17. Rectum communicate with
peritoneum

18.  Pouch like structure in anus and rectum
 Rare anorectal malformations
 The defect is frequently discovered while
rectal temperature is being taken.

19.  There is obstruction about 2cm
above the skin level.These patients
need protective colostomy.

20.  The rectum is completely blind and is
usually found approximately 2cm above
the perineal skin.
 The sacrum and the sphincteric
mechanism are usually well developed .
 A colostomy is indicated during the
newborn period.
 This defect is frequently associated with
down syndrome.

22. GENITOURINARY
 Vesicoureteric reflux
 Renal agenesis
 Ureteral duplication
 Cryptorchidism
 Hypospadiasis
 Bicornuate uterus
 Vaginal septums

23.  VERTEBRAL
 Presacral masses
 Meningocele
 Lipoma
 Dermoid

24. CARDIOVASCULAR
 Tetralogy of Fallot
 VSD
 TGA
 Hypoplastic left heart syndrome

25. Gastrointestinal
 Tracheoesophagel fistula
 Duodenal atresia
 Malrotation
 Hirschsprung disease

26. Low lesions
 Newborn examination reveals absence of an
anal orifice in the correct position
 Normal position of anus is halfway between
the coccyx and the scrotum or introitus
 Primary symptom is constipation
 Cases with anterior ectopic anus have no
symptoms

27.  If no anus or fistula present, it is called
“covered anus”
 After 24 hours meconium bulging may be
seen creating a blue or black appearance.
In male, the perineal fistula may track
anteriorly along the median raphe across the
scrotum and even down the penile shaft, this is
usually a thin track, with a normal rectum
often just a few millimeter from the skin

28.  In females, a low lesion enters the
vestibule or fourchette.
 In this case, the rectum has
descended through the sphincter
complex.

29.  In a boy with high imperforate anus, the
perineum appears flat
 There may be air or meconium passed via
the penis (urethra) when the fistula is
high
 In rectourethral fistula, the sphincter
mechanism is satisfactory, the sacrum
may be bifid and the anal dimple is near
the scrotum

30.  In retrovestibular fistulas, the sphincter
mechanism is poorly developed and
sacrum is hypoplastic or absent.
 In boys with trisomy 21, all the features
may be present, but there will be no
fistula, the sacrum and sphincter
mechanisms are usually well developed
and prognosis is good.

31.  In girls with high imperforate anus, there
may be the appearance of a rectovaginal
fistula.
 A true rectovaginal fistula is rare. Most
fistulas to the vestibule outside the
hymen orifice.
 These have a good prognosis with a
normal sacrum and anal dimple and intact
sphincter function

32.  Clinical evaluation and a urinalysis –
male
 Perineal inspection - females

33.  Invertogram

34.  Mainly required before redo surgery.
 Clearly shows the anatomy of sphincter
muscles, levator ani, muscle complex.
 Delineates the rectal pouch and fistula.
 Clearly shows the relationship between
intestine and surrounding muscles.

35.  Provides exquisite soft tissue imaging in
all three plane.
 Better than CT in soft tissue imaging and
no radiation hazard.
 Scan is expanded to include pelvis ,
kidneys and spinal cord.
 Clearly shows whether the pulled through
intestine is within levator ani sling or not

36.  Early decision-making
 IV line - fluids and antibiotics
 Insertion of nasogastric tube is inserted
 Meconium is usually not seen at the
perineum in a baby with a recto-perineal
fistula until at least 16–24 hours.

37.  Clinical inspection of the buttocks -
flat "bottom" or flat perineum
Operation can be performed during
newborn period, and after 1year
corrective surgical repair is
performed
 colostomy or an anoplasty

38.  Clinical evaluation and urine analysis
 X-ray, cross-table lateral film with
the baby in prone position
 colostomy

40.  Surgically created opening between the
colon and the abdominal wall to allow
fecal elimination.
 It may be temporary or permanent
diversion
 TPYES
 Transverse colostomy
 Descending colostomy

41.  DESCENDING COLOSTOMY
 made from the descending portion of the
colon located in the lower-left quadrant of
the abdomen, with separated stomas . The
proximal stoma is connected to the upper
gastrointestinal tract and drains stool. The
distal stoma is connected to the rectum and
will drain small amounts of mucus material.

43.  Performed at 1–2 months of age
 90% of male patients done anorectal repair,
 while 10% require laparotomy
Rectobladder neck fistula
 operation involves both a posterior sagittal
incision and an abdominal component, which
can be done with laparoscopy or laparotomy.

44.  Rectovestibular fistula is the most common defect in
girls and has an excellent functional prognosis.
 The diagnosis is based on clinical examination.
A meticulous inspection of the neonatal genitalia allows
the clinician to observe a normal urethral meatus and a
normal vagina, with a third hole in the vestibule, which
is the rectovestibular fistula .

46.  The laparoscopically-assisted anorectal
approach consists in mobilizing and bringing
the rectum through the pelvic floor sphincter
muscles through a minimal posterior
incision. Perianal dissection towards the
laparoscopic light source favours accurate
placement of a trocar to pull the rectum
through the external sphincter muscle
complex

47. o Thorough physical examination by the
attending nurse to identify anorectal
malformation
o kept nil per orally
o Colostomy care
o Start feeding after the child has recovered
from anaesthesia

48.  After the diagnosis of occlusion had been
made, gastric suction may be used.
 IV feeding and nasogastric suction help
prevent abdominal distension immediate
post operatively
 Keep the anal site clean and dry
 Diaper should not be used.
 The dressing must be changed frequently

49. Wound infection and retraction
 Incontinence
 Strictures (rectal or vaginal)
 Acquired atresias
 Recurrent fistulas
 Severe pelvic fibrosis
 Rectal mucosal prolapsed
 Constipation