This lateral pelvic x-ray (radiography) demonstrates a contrast-enhanced fistulogram in a neonate with an anorectal malformation (imperforate anus). The diagnostic image highlights a distended, contrast-filled distal rectal pouch positioned superior to the expected level of the anal opening. A long, narrow, radiopaque fistulous tract is visible, originating from the perineal skin surface (vestibular region) and ascending superiorly to communicate with the rectal pouch. A radiopaque ruler is placed externally along the posterior-inferior margin to measure the distance between the skin surface and the terminal end of the rectum, a critical measurement for classifying the malformation as high, intermediate, or low. The vertebral bodies and sacrum are visible, providing anatomical landmarks for evaluating the height of the rectal pouch relative to the pelvic floor. This study is essential for surgical planning, specifically for determining the approach for a posterior sagittal anorectoplasty (PSARP).

This diagnostic X-ray image is a lateral contrast cologram of a pediatric male patient, illustrating high-type anorectal malformation. The study reveals anorectal agenesis, characterized by a blind-ending distal rectum that fails to reach the perineum. A clear fistulous communication (rectourethral fistula) is demonstrated, where contrast medium flows from the distal rectum into the bulbar segment of the urethra, indicated by a black arrow. The radiograph shows simultaneous opacification of the rectal pouch, the fistulous tract, and the lower urinary tract, including the urethra. This finding is clinically significant for surgical planning in cases of imperforate anus where meconium may be observed in the urine. The image serves as an educational example of congenital urogenital and gastrointestinal anomalies, specifically highlighting the anatomical relationship between the rectum and the bulbar urethra in intermediate to high-level anorectal malformations.

This diagnostic image is a lateral invertogram (Wangensteen-Rice view) of a neonate, a specialized pediatric radiograph used to evaluate anorectal malformations. The infant is positioned in a prone, head-down (inverted) posture to allow bowel gas to rise toward the perineum. A radiopaque marker is placed on the skin surface at the expected site of the anus. The radiograph reveals significant bowel gas distension with multiple dilated intestinal loops, consistent with a distal bowel obstruction. The distance between the most distal rectal gas bubble and the external perineal marker is used to classify the malformation as a 'high' or 'low' type defect. Anatomical landmarks visible include the infant's lumbar and sacral spine, pelvis, and femur, showing age-appropriate incomplete ossification. This imaging modality is critical in pediatric surgery for planning the initial management and surgical approach for congenital imperforate anus.

This diagnostic image is a cross-table lateral X-ray of a newborn infant in a prone position, often referred to as an invertogram or Wangensteen-Rice view. The imaging primary focus is the evaluation of anorectal malformations (ARM). The skeletal system is clearly visible, showing the vertebral column with individual vertebrae and spinous processes, the rib cage, and the pelvic girdle comprising the ilium, ischium, and pubis. The femur and tibia of the lower extremities are flexed. The abdomen contains multiple radiolucent (dark) air-filled bowel loops. A key diagnostic feature is the distance between the most distal gas bubble in the rectum and the perineal skin (often marked with a radiopaque marker), used to determine the level of the atresia (high, intermediate, or low). This clinical imaging modality is essential for surgical planning in neonates presenting with imperforate anus to differentiate between various types of anorectal anomalies and associated fistulas.

This diagnostic image is a lateral abdominal and pelvic X-ray of a neonate, positioned in an inverted or 'head-down' orientation for the Wangensteen-Rice technique. The radiograph shows gas-filled bowel loops, specifically outlining the distal rectum as the air rises to the highest anatomical point in this position. A radiopaque metallic marker is placed externally on the perineal dimple to serve as a reference point. The primary educational focus is the assessment of an anorectal malformation (imperforate anus). The image allows for the measurement of the distance between the distal rectal gas bubble and the perineal marker, which is critical for classifying the defect as a 'high' or 'low' lesion and determining the appropriate surgical approach. This clinical application is most valid after 14–24 hours of life to ensure bowel gas has reached the terminal rectum. The imaging highlights key findings in pediatric radiology and neonatal gastrointestinal surgery.

This diagnostic image is a contrast-enhanced colostogram (X-ray radiography) of a pediatric patient, likely an infant, focused on the lower abdomen and pelvic region. The imaging shows a gastrografin contrast medium introduced through a sigmoid colostomy site, filling the distal colon. The radiopaque contrast clearly delineates a blind-ending rectal pouch, characteristic of anorectal malformation (imperforate anus). Crucially, a thin, fistulous tract is visible extending inferiorly from the rectal pouch and terminating at the vulval vestibule, confirming a rectovestibular fistula. The surrounding skeletal anatomy reveals the lumbar spine, pelvic bones, and proximal femurs, which serve as landmarks to assess the level of the rectal pouch relative to the puborectalis muscle and pelvic floor. This image is medically significant for pediatric surgery and gastroenterology, as it demonstrates the morphology of high/intermediate anorectal malformations and guides posterior sagittal anorectoplasty (PSARP) planning.

This clinical photograph captures an intraoperative view of a posterior sagittal anorectoplasty (PSARP) for the correction of an anorectal malformation. The image demonstrates a surgically opened, dilated rectal pouch being held apart by multiple surgical forceps. Within the lumen of the reddish-pink rectal tissue, a rare anatomical finding known as a rectal diaphragm is visible. The diaphragm appears as a raised, circular, obstructive shelf of tissue located approximately 2 cm proximal to the distal end of the pouch. A surgical metal probe or sound is positioned within the lumen to highlight the anatomical relationship between the distal blind pouch and the proximal obstruction. The visual evidence illustrates a complex variant of anorectal atresia where internal septation complicates the identification of the proximal bowel lumen during corrective surgery. This photograph is intended for pediatric surgery education, specifically regarding the identification of atypical internal obstructions in neonates and children with anorectal malformations.

A top-down comparison photograph featuring two synthetic perineal sponge models used for surgical simulation training of the Posterior Sagittal Anorectoplasty (PSARP) procedure. Both models are oval-shaped, light peach in color, and framed by blue sterile surgical drapes. The left model represents the preoperative state, showing a smooth surface with a small, central red marking indicating the planned site for the anorectal malformation (ARM) repair. The right model represents the postoperative state, demonstrating the results of surgical intervention. Key features include an orange material at the original marking site to simulate the transposed rectum and a vertical line of blue surgical sutures extending inferiorly, representing the closure of the sagittal incision. This comparison illustrates the anatomical changes and surgical steps involved in pediatric colorectal reconstructive surgery, including sagittal incision, dissection, and anoplasty, for educational and procedural validation purposes.

This medical illustration depicts a surgical stage of a posterior sagittal anorectoplasty (PSARP) for the management of a congenital anorectal malformation. The diagram shows the pelvic anatomy from a lateral-posterior perspective. Central to the image is the mobilized sigmoid colon, shown as a long, haustrated tubular structure being transitioned toward the posterior sagittal space. To the left, the urinary bladder is visualized with its connection to the lower urinary tract. Adjacent to it is a blind-ending distal rectal pouch, which has been surgically separated from the proximal bowel. The pelvic floor musculature, including the levator ani and muscle complex, is rendered in red, illustrating the tunnel created for the pull-through procedure. On the right, the sacrum and vertebral column serve as anatomical landmarks, highlighting the retrorectal pathway used for the sigmoid mobilization. This educational illustration demonstrates the surgical technique of bypassing a dilated rectum to utilize the healthy sigmoid colon for neo-anus construction.

This clinical photograph shows the perineal and sacral region of a pediatric patient immediately following a Sagittal Sacroperineal Anorectoplasty (SSARP) for the correction of an anorectal malformation. The patient is in a prone position, surrounded by green surgical drapes. Two distinct surgical closure sites are visible. Superiorly, a horizontal (transverse) incision located just above the coccygeal region is closed with approximately four dark-colored, non-absorbable interrupted sutures. Inferiorly, a vertical incision at the newly created anal site is closed with a continuous suture pattern using similar dark material. Notably, the posterior midline skin between these two incisions remains entirely intact and spared, a characteristic feature of the SSARP technique that distinguishes it from the Posterior Sagittal Anorectoplasty (PSARP). The surrounding skin appears healthy with no signs of excessive inflammation, significant edema, or bruising. This image serves as a clinical example of postoperative anatomy in pediatric colorectal surgery, illustrating successful wound closure with preservation of midline skin integrity.

This surgical simulation infographic details the sequential steps of a Posterior Sagittal Anorectoplasty (PSARP) for Anorectal Malformation (ARM) using a synthetic training model. The procedure is shown in five distinct intraoperative stages. Step 1 (Traction Sutures) demonstrates the placement of silk and colored sutures at the ectopic anal site to provide orientation and traction. Step 2 (Sagittal Incision) shows a vertical midline perineal incision with the skin edges retracted by stay sutures to expose deep tissues. Step 3 (Dissect Rectum) depicts the mobilization of the rectum, represented by a beige balloon-like structure, through the sagittal opening. Step 4 (Reconstruction) shows the anatomical repositioning and tapering of the rectum within the muscle complex. Step 5 (Anoplasty) illustrates the final closure, where the rectum is sutured to the skin to create a new anal opening, featuring visible blue and white interrupted sutures. The series serves as an educational tool for pediatric surgical trainees to visualize surgical landmarks, tissue manipulation, and suture techniques required for repairing anorectal defects.

An intraoperative clinical photograph documenting a posterior sagittal anorectoplasty (PSARP) or similar anal transposition procedure for an anorectal malformation. The surgical field focuses on the perineum of a patient in the lithotomy position. A new anal opening has been surgically created through the identified striated muscle complex (sphincter). A gloved hand and surgical instruments, including fine-tipped forceps and hemostats, are visible manipulating the raw, vascularized perineal tissues. Stay sutures are in place to provide traction and exposure of the operative site. The image shows the newly formed ovoid opening with some internal mucosal or rectal tissue visible at the margins. Visible blood and tissue inflammation are consistent with an active surgical dissection. This visual illustrates the surgical management of imperforate anus or rectovestibular fistula in an adult patient, emphasizing the creation of a neo-anus within the sphincteric muscle complex.