The posterior sagittal trans-sphincteric approach

Abstract

The posterior sagittal, transphincteric approach to treat different pelvic problems has been known since last century. Although some surgeons have embraced it and have enthusiastically advocated it s use, it has never become an overly popular technique. The purpose of this study is to evaluate the advantages and disadvantages of the approach, both from an historical perspective and from the authors experience. The international literature on the subject was reviewed since 1877 up to the present date. A retrospective evaluation of the authors experience was conducted, and the results reviewed. Specific attention was paid to the final result obtained in the treatment of the original condition, surgical complications and the effect of the surgical approach on bowel and urinary control. The experiential review included 114 cases. They were divided into two groups. A included 85 patients who underwent a posterior sagittal transphincteric approach that included 49 cases of Hirschsprung s disease (primary 21, secondary 28), 15 presacral masses; 10 rectaltumors; 7 acquired rectogenito- urinary fistulae; and 4 cases of idiopathic rectal prolapse. Group B included 29 patients who underwent a posterior sagittal trans-anorectal approach, in which theanterior wall of the rectum and the sphincter was divided as well.. This group included 12 cases of urogenital sinuses; 8 acquired urethral stricture or atresia after trauma; and 9 posterior urethralmasses. Post-operative bowel control was normal all cases except in those patients whose basiccondition had resulted in fecal incontinence, or who had sustained an irreversible injury prior tothe operation. Urinary control was normal except in cases with pre-operative incontinence. Complications included recurrence ofrecto-genitourinary fistulae in 3 cases, recto-cutaneous fistula in 3 Hirschsprung s patients and 2 partial wound dehisences. The posterior sagittal trans-sphincteric approach represents a useful technical alternative. It seems to be particularly useful to treat complications after surgery for Hirschsprung s disease, pre-sacral masses, acquired recto-genito-urinary fistula and idiopathic rectal prolapse. Thetransanorectal approach provides excellent exposure to the posterior urethra and vagina. Boweland urinary control are not compromised.