Objective: To document our experience of the primary anterior sagittal anorectoplasty (ASARP) in female patients with lower and wide fistula in term of the early post operative outcome. Methods: A retrospective descriptive study was conducted in one surgical unit of the National Institute of Child Health Karachi, from January 2010 to April 2018. The study included female patients with diagnosis of imperforate anus with wide Vestibular or Perineal fistula with minimal or no straining during defecation and no excoriation of perineum. All patients underwent primary ASARP. Data regarding the age of the patients, site of fistula, the difficulties in dissection, post operative complications, stoma and re-do ASARP needed, were documented. Wound assessment was done during hospital stay, at two weeks and then at three months after surgery. Outcome was documented in terms of complications of surgery and cosmetic appearance of perineum. Data was analyzed on SPSS version 20. Results: A total of 70 patients underwent primary surgery, 48(68.57%) females had perineal fistula while 22(31.42%) had vestibular fistula. Age ranges between three months to 276 months with median of 6±39.73 months. No major injury to the rectal or vaginal wall occurred during surgical procedure. In early post-operative period, 12(17.14%) patients had wound infection with or without various extent of disruption. A total of seven (10.11%) patients underwent stoma formation, six (8.57%) patients because of wound disruption with in a week of primary surgery and in one patient due to severe anal stenosis and retraction of anal segment within three month follow up. Median hospital stay was 5±1.52 days. In 38(54.28%) paients complete wound healing occurred with no per or post operative complications. In 25(35.71%) patients, minor complications were noted and treated accordingly and results were labelled satisfactory with acceptable perineal appearance. Conclusion: The single stage procedure can be a good choice for both vestibular and perineal fisula. In majority of cases wound heals completely with minimal or no scaring and give good cosmetic results. doi: https://doi.org/10.12669/pjms.36.3.1503 How to cite this:Zamir N, Rasool N. The early outcome of primary anterior sagittal approach for low anorectal malformations in female patients. Pak J Med Sci. 2020;36(3):---------. doi: https://doi.org/10.12669/pjms.36.3.1503 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

RESULTSOf the nine patients who presented with ED, nearly two-thirds were infants (age range 3 months-5 years). Seven (77.8%) were male and two (22.2%) were female. The presenting symptoms were varied, with the most common being abdominal mass and bleeding per rectum. Descriptions of the patients' age and gender, clinical features, main investigations, types and sites of cysts, surgical procedures performed and complications observed are RESULTS A total of nine patients were managed during the study period. The patients' ages ranged from three months to five years. Four out of nine EDs were rectal duplications. Three EDs were of the cystic type, five were of the tubular type and one was a complex mixed anomaly. Patients presented with varied symptoms, with the two most common being the presence of an abdominal mass and bleeding per rectum. Diagnosis was mainly achieved based on magnetic resonance imaging and computed tomography, although Meckel's scan provided accurate diagnosis in three of the nine patients. All the cysts were resected without any major complications, and patients were event-free during the five-year follow-up. Table I. A total of four out of nine patients had rectal duplications, and a perineal mass was noted in one (11.1%) patient. One patient had infected wound discharge following drainage of a perineal abscess, while penoscrotal hypospadias was present in another. (2) Although ED may present at any age, a majority are also why EDs may pose as a diagnostic challenge. In the present study, none of the patients were diagnosed antenatally. CONCLUSIONSome patients, however, had unusual symptoms -one patient presented with a nonhealing wound in the perineum that had previously been incised and drained due to suspicions of it being a perineal abscess, although a closer look at the surface would have revealed the presence of mucosa in the deeper part of the wound. Only one patient in our series had associated penoscrotal hypospadias. Such anomalies have been reported in up to 50% of patients, with vertebral defects being the most common.(1)EDs may be cystic, tubular or mixed (cystic and/or tubular).Although EDs usually communicate with adjacent parts of the gut, instances of completely isolated duplication cysts have also been reported. (6) We found various types of duplication cysts in our patients, including the cystic, tubular and complex mixed varieties. According to the literature, the ileum is the most common site of ED, whereas gastric and colonic duplications are rare, (4) and thoracoabdominal duplications are the most challenging. (7)(8)(9) In our series, the ileum was the most commonly involved site (n = 5), presenting as either an isolated lesion or a combination. However, contrary to the literature, which does not describe a high incidence of rectal involvement, (7,9,10) our series saw four cases (out of a total of nine) of rectal involvement. Also, there was a higher incidence of tubular ED (n = 5) in our study. Interestingly, one patient had a rare, complex duplication cyst that s...

Introduction: Circumcision remains the commonest performed surgical procedure in outpatients. Circumcision with Plastibell is the most popular used method of circumcision among surgeons. As any other surgical procedure, it inherits complications, bleeding being the commonest. The aim of this study is to compare the incidence of post-operative complications in circumcision performed with Plastibell with and without coagulation hemostasis in male infants in the outpatient department of Pediatric Surgery, Combined Military Hospital, Lahore. Methods: This study assesses the data of all infants circumcised in outpatient department with Plastibell. All infants were divided in two groups. In Group A, total 170 circumcisions were performed without frenular hemostasis. In Group B, total 193 circumcisions were performed with frenular hemostasis, over the total period of 2 years. Results: Among 170 patients in group A, 30 patients had complication, out of which 28 had bleeding. In group B, after coagulation hemostasis of frenular band, 193 circumcisions were done. Only 2 patients out of 193 had complications. None of them had post circumcision bleeding. Frenular band was found and coagulated in 98 (50.77%) patients. Conclusion: Circumcision with Plastibell in infants is a safe procedure; post circumcision bleeding can be avoided by careful application of Plastibell and dealing with frenular band with coagulation hemostasis.

Background: Hypospadias is a field of continuous evolving surgery. The aim of surgical treatment is to restore the normal appearance and function of Penis. The outcome of surgery largely varies and depends upon type and severity of anomaly, associated factors, type of surgery performed and skills of surgeon. Study Design: Descriptive, prospective study. Setting: Department of Pediatric Surgery, Military Hospital Rawalpindi and Combined Military Hospital Lahore. Period: 07 years, from October 2010 to October 2017. Methods: Report and analyze the types of hypospadias, choice of surgery along with outcome of surgical repair. All patients operated for Hypospadias surgery were divided in three groups according to age for the purpose of convenience of data collection. Results: A total of 142 surgeries were done on 131 patients were operated (In 09 patient’s stage 2 was performed). Distal penile hypospadias was the most common variety. One stage repair was performed in 83 patients. Two staged repair was decided in 59 patients. Among them 09 are done with second stage urethroplasty. Urethrocutanous fistula was the most common complication in 31 patients followed by bleeding, blocked tube, urine leakage from meatus, splayed stream, wound infection, disrupted glans, torsion of penile shaft and meatal stenosis. Conclusion: Hypospadias surgery is a continuous learning process, one should master in one or two techniques with its intricacies. Meticulous preoperative assessment of anomaly, accurate selection of surgical procedure, proper tissue handling and vigilant follow up are required for good outcome and least complications.

… Anorectal malformation is the common congenital malformation. Ectopic anusand vestibular fistula are Intermediate types of anorectal malformations (ARM), which are themost common in female babies. Many surgical procedures have been described for the treatmentof ARM. Anterior Saggital Anorectoplasty (ASARP) is not only convenient for the anesthetist formaintenance of anesthesia but also gives better exposure of surgical structures during surgery.Objectives: To determine the technical suitability and outcome of ASARP in intermediate typesof ARM in female children. Design: This Descriptive study with prospective collection of dataaccording to a set protocol. Setting: The study was carried out at the department of PediatricSurgery, Military Hospital, Rawalpindi, Pakistan. Period: November 2010 to March 2014, overthe period of 3 years and 5 months. Patients and Methods: The data of all female patientspresenting with intermediate types of ARM and undergoing ASARP, during the study periodwere analyzed, with respect to age, type, associated anomalies, complications and cosmeticoutcome. Results: A total of 36 patients of intermediate variety underwent ASARP. Age rangedfrom 6 months to 22 years. All patients had colostomy prior to this procedure. During surgery,posterior vaginal wall tear occurred in 2 patients (5.5%). Postoperatively, 2 patients (5.5%) hadretention of urine, 2 patients (5.5%) developed wound infection with superficial disruption, analstenosis occurred in 2 patients (5.5%) and 1 patient (2.7%) had rectal mucosa prolapse. Noneof them required re_ do surgery. Cosmetic outcome was excellent in 31 patients (86.1%), while itwas satisfactory in 5 (13.8%) patients. Conclusions: Anorectoplasty through anterior approachis not only technically easy but has good cosmetic results in intermediate type of imperforateanus in female children.