A Modification of the Heineke–Mikulicz Concept Applied to the Treatment of Congenital Anal Stenosis

Abstract

Introduction:

Anal stenosis is a rarely seen type of anorectal malformation for which a variety of treatments have been described, including cutback anoplasty, posterior sagittal anorectoplasty (PSARP), and a formal anoplasty, all done with or without colostomy, with inpatient stays and a significant anorectal dissection. The aim of this video is to demonstrate the use of an innovative and less invasive technique to treat congenital anal stenosis in a 2-year-old boy.

Materials and Methods:

The patient presented with recurrent episodes of constipation and fecal impaction from birth. He was found on examination to have anal stenosis, with a 2 mm depth of narrowed area and healthy rectum more proximal to this. Under general anesthesia, he was positioned prone, traction silk stitches were placed on the anal skin circumference, and radial incisions were made using cautery on the skin and adjoining mucosa, sequentially, at the 12, 3, 6, and 9 o'clock positions to release the stenosed ring. The resulting rhombus became a concentrically oriented line with a pull on the traction sutures, and this was then closed mucosa to skin.

Result:

The patient's anal size increased from a Hegar dilator size 9 to 16 immediately. The anal canal and dentate line were preserved, and no rectal mobilization was performed. The surgery lasted 12 minutes. He did well clinically and was discharged on the first postoperative day after passing normal stools.

Conclusion:

The Heineke–Mikulicz technique can be adapted for management of congenital anal stenosis through a minimally invasive treatment that preserves the dentate line and anal canal, and is useful for narrow, skin level strictures. The technique has potential application to other thin strictures, such as those occurring post PSARP.

No competing financial interests exist.

Runtime of video: 2 mins 24 secs