Duplication dilemma: A tale of two openings

Abstract

A 4-year-old female presented with a perianal opening on a background of chronic constipation, mucus discharge from the perianal area and abdominal pain since birth. On initial examination, there was a small pinhole, external, opening at 6 O'clock with a prominent external anal blood vessel. Ultrasound showed a small opening adjacent to the anus and a small tract measuring 12 Â 2 mm opening along the anal canal. Further imaging with magnetic resonance imaging showed an anteriorly positioned rectum, with loss of normal vertical anorectal angle, and an abnormality anterior to the sacrum and paralleling the anal canal down to the anal verge. Both internal and extrinsic anal sphincters had a normal appearance. The probable diagnosis was of a collapsed sinus and the patient underwent an examination under anaesthetic which showed a 2-cm deep perineal tract that had no communication with the anorectum. The patient had no urogenital or spinal anomalies.The patient underwent surgical excision of the ano-perineal tract; she was admitted 2 days prior to surgery for bowel preparation due to her longstanding constipation. The patient was positioned prone, and a circumferential incision was made around the external opening and extended posteriorly in the sagittal plane. Bipolar diathermy was then used to dissect proximally with the aid of a nerve stimulator to identify muscle complex. The posterior wall of the tract was continuous with the rectal wall. The tract was traced proximally to its blind-ending and excised. There was no connection or breach of the rectum. The