TUGAS BEDAH

MANAGEMEN ATRESIA ANI

Disusun oleh:
1. Ririn Halimatus Sa’diyah 16700091

Kelas: 2016 C

FAKULTAS KEDOKTERAN
UNIVERSITAS WIJAYA KUSUMA SURABAYA
TAHUN AKADEMIK 2019/2020
 TABLE OF CONTENTS

TITLE PAGE
TABLE OF CONTENTS ........................................................................................ 1
BAB I
FOREWORD ............................................................................................................. 2
A. BACKGROUND ........................................................................................... 2
BAB II
LITERATURE REVIEW .......................................................................................... 3
A. INTRODUCTION .........................................................................................
B. EPIDEMIOLOGY .........................................................................................
C. EMBRIOLOGY .............................................................................................
D. CLASSIFICATION .......................................................................................
E. ETIOLOGY ...................................................................................................
F. PATOFISIOLOGY ........................................................................................
BAB III
DISCUSSION ............................................................................................................ 4
A. CLINICAL MANIFESTATION ...................................................................
B. SURGICAL MANAGEMENT ......................................................................
C. MANAGEMENT ...........................................................................................
D. TREATMENT
BAB IV
RESULTS AND DISCUSSION ................................................................................ 5
REFERENCES ......................................................................................................... 29
 BAB I
FOREWORD
A. Background
Atresia ani or anus imperporata is a congenital malformation in which the
rectum does not have an outward hole (Wong, 2004). Most of the prognosis of
atresiaani is usually good if it is supported by appropriate treatment and also depends
on the anatomical location at birth. Anesthesia ani if not treated promptly there can be
complications such as intestinal obstruction, constipation and incontinence.
The life of urban society is closely related to population density, and air
pollution. The difficulty of finding work for urban people with low education makes
many urbanites at the lower middle economic level. well. The low level of education
and economic level is very possible limiting families with pregnant women exposed to
health information about pregnancy nutrition. Nutrients consumed by mothers during
pregnancy are believed to affect fetal development. Air pollution from cigarette smoke
/ nicotine is associated with fetal growth retardation and increased infant and perinatal
mortality and morbidity (Bobak, 2005). Atresia ani is a congenital disorder that can be
influenced by genetic and environmental factors or both.
Atresia ani occurs in 1 out of every 4000-5000 abnormalities of life. In general,
atresia ani is more common in men than women. Rectourethral fistula is the most
common disorder found in male infants, followed by perineal fistula. Whereas in female
babies the type of atresia ani which is most commonly found is atresia ani followed by
rectovestibular fistula and perineal fistula (Oldham K, 2005).
High-level atresia requires the management of a gradual operation which is the
making of colostomy, manufacturing of the anal canal / PSARP (posterior sagital
anorectoplasty), and finally the closing of the colostomy. long, and long days of care
cause trauma to the child. Nurses play an important role in reducing the effects of
hospitalization on children, especially pain.
The world of children is the world of play, especially for children aged 1-3
years. The growth and development must be maintained with the stimulation efforts
that can be done, even if the child is treated in hospital. Playing on children in hospitals
as a medium for children to express feelings, relaxation, and distraction of
uncomfortable feelings (Supartini, 2004). Music therapy can be used as an alternative
in minimizing pain and discomfort in hospitalized children as part of a children's play
program.
 BAB II
LITERATURE REVIEW
A. Introduction
Atresia is the most commonly reported anamoly of the anus and rectum
(Roberts, 1986). Anal atresia is the failure of the anal membrane to break down to make
an anal orifice and it has been reported as the most frequently encountered anamoly in
calves (Das and Hashim, 1996). The causes of this congenital defects may be genetical
or environmental of both, but in many cases the cause is unknown (Bademkiran et al.,
2009). The most common bovine environmental teratogens include toxic plants
consumed by the dam and maternal- fetal viral infections during gestation and the
majority of genetic defects in cattle are inherited as recessives (Newman et al., 1999).
Four major types of anal and rectal atresia were reported including congenital anal
stenosis (Type I), imperforate anus alone (Type II), or combined with more cranial
termination of the rectum as a blind pouch (Type III) and discontinuity of the proximal
rectum with normal anal and terminal rectal development (Type IV) (REMI-
Adewunmi et al., 2007). Occasionally, rectum becomes ruptured due to abdominal
straining of animal forming a recto-vaginal fistula, that allows the excreta to pass out
through vulvular opening (Muhammad et al., 2015).
Atresia ani is a congenital abnormality known as the imperforate anus including
the anus, rectum, or the boundary between the two (Betz, 2002). Anaeresia ani is a
congenital disorder, there is no hole or anal canal (Donna, 2003). incomplete embryonic
development in the distal anus or abnormal closure of the anus (Suradi, 2001).
Anesthesia anus or an imperforate anus is the absence of membrane perforation that
separates the endotherm causing an imperfect anal opening. Anus appears flat or
slightly concave into or sometimes concave in the form of anus but not directly related
to the rectum (Purwanto, 2001).
Atresia ani is also called anorectal anomaly or imperforate anus. Is a congenital
disorder in which anorectal abnormal development occurs in the gastrointestinal tract.
Atresia ani or perusimperporata is a congenital malformation in which the rectum does
not have a hole out (Wong, 2004).
Anal atresia / Atresia rectal is the absence or closure of the rectal congenitally
(Dorland, 1998). Atresia ani is a congenital abnormality known as perforated anus
including the anus, rectum or both (Betz.Ed 3, 2002). Atresia ani is a congenital
abnormality, the absence of holes or anal canal (Donna L. Wong, 520: 2003).
 The author concluded that atresia ani is a congenital abnormality in which the
anus does not have a hole to excrete faeces due to disruption of the cloaca separation
that occurs during pregnancy.
B. Epidemiology
The average incidence rate of anorectal malformations worldwide is 1 in 5000
births.2 In general, anorectal malformations are more common in males than females.
Rectourethral fistula is the most common disorder in male infants, followed by perineal
fistula. While in female infants, the most common type of anorectal malformation is
the imperforate anus followed by rectovestibular fistula and perineal fistula.

The results of Boocock and Donna's research in Manchester show that low-lying
anorectal malformations are more common than high-lying anorectal malformations.

C. Embriology
The intestine forms the distal third of the transverse colon, descending colon,
sigmoid, rectum, upper part of the anal canal. Emdodern of the back intestine also forms
the inner lining of the bladder and urethra (Sadler T.W, 1997).

The end of the back intestine empties into the cloaca, a cavity lined with
endoderm that is directly related to the surface ectoderm. The meeting area between the
endoderm and the ectoderm forms the cloaca membrane (Sadler T.W, 1997).

In further development, a transverse rash arises, the urorectal septum, at an

angle between the allantois and the back intestine. When the embryo is 7 weeks old,
the urorectal septum reaches the cloaca membrane, and in this region a corpus parienalis
is formed. The cloacal membrane then divides into the analytical membrane in the back,
and the urogenital membrane in the front (Sadler T.W, 1997).

Meanwhile, the membrane of the analyst is surrounded by mesenchymal bumps,

known as the anal canal or proctodeum. In the 9th week, the membrane membrane is
torn, and the path is opened between the rectum and the outside world. The upper part
of the anal canal comes from the endoderm and is degraded by vessels the back of the
intestine, namely the inferior mesentrika artery. However, the lower third of the anal
canal comes from the ectoderm and the ectoderm is formed by the linea pectinata, which
is located just below the column of the analyst. TW, 1997).
 By embryology, the digestive tract comes from the foregut, midgut and hindgut.
Foregut will form the pharynx, lower respiratory system, esophagus, gastric duodenum,
liver and biliary system and pancreas. Midgut forms the small intestine, part of the
duodenum, cecum, appendic, ascending colon to mid transverse colon. The hindgut
extends from the midgut to the cloacal membrane, this membrane is composed of
cloacal endoderm, and the ectoderm from the protoderm or analpit. gut. Failure of
complete development of the urorectal septum results in anomalous high or supra
levator anomalies. While low anomaly or infra-levator anomalies originate from
developmental defects of proctoderm and genital folds. internus can be absent or
rudimentary (Faradilla, 2009).

D. Classification
The most commonly used classification for anorectal malformations is the
Widespread classification which divides anorectal malformations into high, intermedia
and low locations. However, for therapeutic and prognostic purposes, classifications
are made based on type.
Melbourne divides based on the pubokoksigeus line and the line that passes
through the ischii abnormality is called:
1. High position if the rectum ends above the levator ani muscle (musculus
tuberculosis). High Disorders (High Anomaly / Supralevator Disorders). High
abnormalities have several types, among others: males have anorectal agenesis,
rectouretral fistulae, namely the appendix rectum has no connection with the urinary
tract, fistula to prostatic urethra. The rectum terminates above the puborectal muscle
and the levator ani muscle, there is no internal sphincter. Women have anorectal
agenesis with high vaginal fistula, which is a fistula between the rectum and the
posterior vagina. In men and women usually rectal atresia.
2. The location of the intermediates if the rectum suffix is located in the levator ani
muscle.
Intermediate Anomaly, its characteristics are that the tip of the rectum reaches the level
of the Levator ani muscle but does not penetrate it, the rectum descends through the
puborectal muscles to 1 cm or right in the puborectal muscles, there are anal dimples
and external sphincter. Types of intermediate abnormalities include, for men,
rectobulbar / rectouretral fistula (small fistula from rectal pouch to bulbar), and anal
 agenesis without fistula. Whereas for women it can be rectovagional fistula, analgenesis
without fistula, and rectovestibular fistula.
3. Location is low if the rectum suffix ends below the levator ani muscle.
Low Anomaly, the characteristic is that the rectum descends to the puborectal muscles,
the external and internal anal sphincers are fully developed with normal functions, the
rectum penetrates the levator ani muscle so that the skin and rectum are at a distance of
2 cm. Types of low disorders include anal stenosis, anal membrane imperforata, and
fistulas (for male fistulas to perineum, scrotum or penile surface, and for anterior
ectopic anus or anocutaneus fistula women are perineal, vestibular or vaginal fistulas).

E. Etiology
Atresia ani or imperforata anus can be caused by:

1. genetic factors

Genetic or congenital (autosomal) anus abnormalities caused by growth, fusion and

anus formation from an embryogenic protrusion. In the fifth to seventh week of
gestational age, disruption of the separation of the cloaca into the rectum and urogenital
sinus, usually due to impaired development of the urogenital septum.

2. Disconnection of the digestive tract from above with the rectal area, so that the baby
is born without an anal opening

3. Organogenesis disorders in the womb.

4. Associated with Down syndrome.

5. environmental factors (such as drug use and alcohol consumption during pregnancy)
but this is still unclear (Bobak, 2005).

F. Patofisiology
At the 5th week of gestation, the cloaca develops into the urethra, genital and
rectum. At 6 weeks' gestation, the urorectal septum divides the cloaca into anterior and
intestinalposterior urogenital sinuses. 7 weeks gestation, complete separation of the
rectal and urinary segments. At the 9th week of gestation, the parturogenital already
has an external opening and the anus is covered by a membrane. Atresia ani arises when
there is a disruption in the process.
During bowel movement, meconium passes through the large intestine to the rectum
and then to the anus. Nerves in the anal canal help sensation of bowel movements
(BAB) and also stimulates muscle activity. The muscle helps control faecal discharge
during defecation. In infants with anorectal malformation (atresia ani) some abnormal
conditions occur as follows: the narrow anal canal or misplaced in front of where it
should be, there is a membrane at the time of anal opening, the rectum is not connected
to the anus, the rectum is connected to the urinary tract or the reproductive system
through the fistula, and there is no anal opening.
 BAB III
DISCUSSION

A. Clinical Manifestation
Clinical manifestations in clients with atresia ani include meconium does not
come out in the first 24 hours after birth or out through the urinary tract, vagina or
fistula. In newborns, fecal temperature measurements cannot be taken. Abdominal
distension can occur gradually in the first 8-24 hours. Physical examination found signs
of intestinal obstruction and constipation. Vomiting at 24-48 hours of age or when the
baby is fed also needs attention. Anal opening is limited or there is misplaced anal
opening. More than 50% of clients with atresia ani have other congenital disorders.
B. Surgical Management
The calf was restrained in lateral recumbency. All the 3 anamolies i.e. closing
of vaginal defect, closing of rectal defect and reconstruction of anal opening were
rectified separately. Firstly the perineal region below the base of the tail was prepared
for aseptic surgery. Epidural anaesthesia of 2ml 2% lignocaine was given followed by
local infiltration of 2% lignocaine at surgical site. After development of anaesthesia, a
cruciate incision was given at anal depression. The incision extended forward to secure
the rectum. The muconium expelled to outside. The identified fistulous defect of
vaginal roof was closed using catgut No.1-0 by simple continuous sutures. Afterwards
the rectal defect was also closed by blind suturing after further evacuating the faeces.
The anal opening reconstruction was made by suturing rectal mucosa along with
perianal skin using silk at 3, 6, 9 and 12’o clock position. Further, the patency of the
anal opening was maintained by inserting a 5ml edges smoothened syringe barrel,
sutured to skin by stay sutures (Fig. 2). A course of antibiotics and analgesics were
administered for a period 5 day and 3 days respectively. The newly constructed anal
opening was washed twice daily with normal saline followed by neomycin ointment
application. the syringe barrel was removed after 5 days and the skin sutures were

removed on 12th postoperative day.

C. Management
Management of atresia ani depends on its classification. In high location atresia,
a colostomy must be performed first. At some time ago, the treatment of atresia ani uses
abdominoperineal pullthrough procedures, but this method often causes fecal
incontinence and higher intestinal mucosal prolapse. Pena and Defries introduced in
1982 the method of surgery with the posterior sagittal anorectoplasty approach, which
is by splitting the external sphincter and the levator ani musculature to facilitate the
mobilization of rectal pouches and cutting fistulas.
The successful management of atresia ani is judged by its long-term function,
including its anatomy, physiological function, cosmetic form and anticipation of
psychological trauma. To handle it appropriately, the height of the rectal suffix must be
determined which can be determined in various ways including physical, radiological
and ultrasound examination. Many complications that occur postoperatively are caused
by failure to determine the location of the colostomy, inadequate preparation for
surgery, limited anatomical knowledge, as well as poor operator skills and poor
postoperative care. The various management classifications differ depending on the
location of the height of the rectal suffix and the presence or absence of fistulas.
Pena explicitly explains that at high altitude atresia and intermediates do
colostomy in advance for decompression and diversion. Definitive operation after 4-8
weeks. Currently the most widely used technique is posterosagital anorectoplasty,
whether minimal, limited or full postero sagital anorectoplasty.
Operations Techniques:
1. Performed under general anesthesia, with endotracheal intubation, with the patient
lying on his stomach and pelvic position.
2. Perineal stimulation with the Muscle Stimulator Pen tool for dimple anal
identification.
3. Include the center of the sacrum downward through the center of the spingter and
stop 2 cm in front of it.
4. Split by subcutaneous tissue, fat, parasagital fiber and muscle complex.
5. Os coccyx is divided until the levator muscle is seen, and the levator muscle is split
in the back wall of the rectum.
6. The rectum is freed from the surrounding tissue.
7. The rectum is pulled through the levator, muscle complex and parasagital fiber.
8. Anoplasty is performed and tension is maintained.
 BAB IV
RESSULTS & DISCUSSION

The animal recovered well without any recurrence for a follow-up of 4 months.
Congenital malformations of the rectum and anus are common reported in all species of
animals (O’Connor, 1998). Some deformities are amenable to surgical intervention and some
are incorrigible in nature (Shakoor et al., 2011). Congenital rectovaginal fistula is characterized
by the communication between the dorsal wall of the vagina and the ventral portion of the
rectum, so that the vulva functions as a common opening to the urogenital and gastrointestinal
tracts and is usually associated with type II atresia ani, in which the rectum ends as a blind
pouch immediately cranial to the imperforated anus (Bademkiran et al., 2009), which was also
observed in the present case. Agenesis of vagina, urethra, anus and rectum are discovered rarely
and are attributed to the faults lying in chromatin material (Ghanem et al., 2004). The clinical
signs observed were according to the findings of Bademkiran et al., (2009). Azizi et al. (2010)
described a good survival rate in response to atresia ani rectification by removing a circular
skin piece and unifying the excised rectal loop with skin. Recto-vaginal fistula and atresia ani
are treated commonly by two surgical techniques. In one method, the defects of rectum and
vulvular lips are closed individually after isolating and transecting the fistula (Mahlar and
Williams, 2005). Anal opening is reconstructed later on. In the second method, trisection of
rectum is done just anterior to fistula, the defective rectal part is excised followed by the
suturing of last rectal part with the skin margins of opening carved already at possible anal site.
In the present case, all the anamolies were rectified as reported by Mahlar and Williams (2005).
The heritability of intestinal atresia is controversial but has been reported to be heritable
condition in calves and pigs (Kilic and Sarierler, 2004). Since the clinical signs and physical
examination findings were adequate enough to establish the diagnosis, so radiographic studies
were not necessary. Surgical repair is the only and best possible solution to overcome
congenital anomalies in animals to reduce economic losses to the owners.
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