The anterior sagittal approach to the treatment of anorectal malformations: evolution of the Mollard approach.

Mollard's anterior perineal approach has been used for more than 20 years for the treatment of anorectal malformations and has undergone several modifications. The anterior sagittal approach is a simplification of the Mollard approach. It allows a safe dissection and preservation of the puborectalis sling, a clear identification of the external sphincters and other striated muscle fibers caudal to the puborectalis, and prevents inadvertent damage to the nerve supply. The site of the rectourethral (or rectovaginal) fistula, containing the internal sphincter, is preserved for anastomosis with the anoderm. The rectal cul-de-sac is mobilized minimally to come through the puborectalis under some tension, while the anoderm and external sphincters are also brought up under tension to meet these structures, thereby creating a short anal canal more closely resembling the normal anatomy. This approach can be used for most types of anorectal malformations in both sexes, and usually is combined with a transverse suprapubic laparotomy for supralevator anomalies.