**Acknowledgements**

*Congenital Anomalies in Newborn Infants - Clinical and Etiopathological Perspectives*

Failure to pass meconium in the first 24–48 h of life. Physical exam will reveal abdominal distention and absence of anus. A subtle opening in the perineum through which small amounts of meconium pass may be present and indicates an anoperineal fistula in the setting of a low imperforate anus. This is the most common pathology seen. In females, low lesions may also be associated with a rectovestibular fistula, and meconium may be expressed through the vagina. Elimination of meconium during urination indicates rectourethral or rectovesicular fistula and a high rectal pouch.

Diagnosis is made upon physical examination of the perineum. Historically, an invertogram was performed to evaluate the length of atresia. In this study, a radiopaque marker is placed on the infant's bottom, where the anus would normally be located, and the infant is placed in a head down position to allow air to ascend at the most inferior point in the rectum. Lateral films of the pelvis are then obtained. The distance between the marker and distal rectum indicate the level of pathology—

Anorectal malformations are part of the VACTERL syndrome and most commonly associated with concomitant genitourinary defects. In addition to a renal ultrasound, a voiding cystourethrogram should be obtained, especially if a rectourethral/rectovesicular fistula is suspected as this can help delineate the tract. Plains films of the chest, limbs and spine as well as an echocardiogram help identify the presence of other anomalies. Any other life-threatening co-morbidities take precedence, and a temporary diverting ostomy can be placed until definitive repair can

Posterior sagittal anorectoplasty (PSARP) is the surgical procedure performed. The infant is placed in a prone jack-knife position. If a perineal fistula is present, an incision is made around the fistula and carried posteriorly toward the coccyx. If no perineal fistula is present, the incision starts inferior to the coccyx and is carried down to the perineum. It is imperative to remain midline. This is ensured by visualizing striated muscle fibers, which run perpendicular to the incision. If fat is encountered during the dissection, this indicates that the operator has deviated from midline and entered the lateral ischioanal/ischiorectal space. The rectum is identified by its overlying glistening fascia and then freed circumferentially, beginning posteriorly and advancing anteriorly until the fistula is encountered. The fistula is resected. After the fistula is taken down, the anterior rectal wall is freed from its surrounding structures. In females, the anterior rectum lies in close proximity to the posterior vaginal wall and in males, the prostate and bladder. The anterior rectal wall is gently dissected off these structures up to the peritoneal reflection. Complete, circumferential dissection of the rectum will allow for tension-free pull down and anastomosis. The rectum is situated in its anatomic position in the muscle complex. The muscle complex is repaired around the properly positioned rectum

Long terms outcomes are dependent on the level of pathology—high versus low anorectal dysgenesis—and the extent of neuromuscular development of the levator

*4.2.2 Clinical presentation*

*4.2.3 Diagnosis*

high vs. low. Now, ultrasound is preferred.

*4.2.4 Surgical management*

be safely performed, usually between 8 and 12 months of age.

and the neoanus is created by suturing mucosa to the perineum.

**102**

*4.2.5 Outcomes*

The contribution of Natalia Louise Smith is greatly appreciated for drawing the figures numbered as 1-to-6.
