Operative technique Transanoproctoplasty: a 21-year review Basem A. Khalil, Antonino Morabito ⁎ , Adrian Bianchi Department of Paediatric Surgery, Royal Manchester Children's Hospital, M27 4HA Manchester, UK Received 1 November 2009; revised 3 May 2010; accepted 4 May 2010 Key words: Imperforate anus; Anoplasty Abstract Background: Transanal anorectoplasty was developed through the 1980s by the senior author (AB) as an alternative approach to posterior sagittal anorectoplasty for the management of imperforate anus. This study evaluates this surgical approach and its longer-term results. Methods: Case notes of all patients treated from 1984 to 2005 were reviewed. Operative procedures, colostomy requirement, complications, and long-term outcome were recorded. Patients were grouped according to the status of the pelvic floor, the location of the rectal fistula, and the sacral ratio. Results: A total of 245 patients (175 male, 70 female) underwent transanal anorectoplasty. The perineum was well formed in 208 patients (85%), moderately formed in 15 (6%), and poorly formed in 22 (9%) patients. Two hundred three patients (82.8%) had a visible perineal or vulval fistula, 24 (9.8%) had a prostatic urethral fistula, whereas 18 (7.4%) had a bulbourethral fistula. Overall, 6 patients (2.5%) had wound infection or breakdown. As continence is age related, 32 patients were excluded from the study. Of the remaining 212 patients, 182 are continent with no soiling or only minimal staining. Thirty patients born with a poor perineum are incontinent. Conclusion: Transanal anorectoplasty is a safe procedure with limited morbidity. It is sphincter sparing and permits accurate placement of the rectum with its internal sphincter within the anal canal. The anus lies accurately placed at the center of the external anal sphincter muscle complex. Given a well- performed surgical intervention, eventual continence relates to the original anatomy and neurology of the pelvic floor. Transanal anorectoplasty should be regarded as an alternative rather than as a substitute to posterior sagittal anorectoplasty for reconstruction of most forms of imperforate anus. © 2010 Elsevier Inc. All rights reserved. Several methods have been proposed for the management of imperforate anus. The subject was fraught with mis- understandings until the seminal work of deVries and Peña [1] and the introduction of their landmark procedure, posterior sagittal anorectoplasty (PSARP), which was based on a demonstrably clearer understanding of the pelvic floor and sphincteric anatomy. Posterior sagittal anorecto- plasty involves extensively laying open the posterior perineum and pelvic diaphragm, division of the external sphincter complex in the midline, separation of the rectal fistula from the urethra/vagina, and placement of the rectum within the sphincter complex to anastomose with the anus at the perianal margin. Based on such clearer understanding of imperforate anus anatomy and the realization that, for most forms of the anomaly, PSARP represented an excessive dissection, Bianchi through the 1980s developed the sphincter-sparing transanal anoproctoplasty (TAP) tech- nique. This article describes the technique and its longer- term results over 21 years. ⁎ Corresponding author. Tel.: +1 01619222748. E-mail address: antonino.morabito@manchester.ac.uk (A. Morabito). www.elsevier.com/locate/jpedsurg 0022-3468/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2010.05.005 Journal of Pediatric Surgery (2010) 45, 1915–1919