As discussed in each one of the specific anorectal malformations, patients operated with a protective colostomy that underwent a posterior sagittal repair, without opening the abdomen, are usually fed the same day of the operation. The pain that these patients suffer from is minimal. We try to stay away from strong pain medications, such as morphine. The patients feel comfortable once they feel the presence of the parents. We keep them in the hospital for 48 h in order to administer intravenous antibiotics. We do not have cases of infections after a posterior sagittal anorectoplasty, performed with a protective colostomy. When the patient is discharged home, we ask them to come back to the clinic 2 weeks after the operation, to start the process of anal dilatations. Occasionally, patients suffer from vomiting after the operation; we believe that it is related with the anesthesia, since we did not perform any abdominal surgery.

When we perform a posterior sagittal anorectoplasty without a colostomy as described in the chapter on bowel preparation, the patients receive GoLYTELY®¹; in other words, we clean the entire gastrointestinal tract. They also receive a PICC line or central venous catheter in order for them to receive parenteral nutrition. We tell the family that the patient will remain with nothing by mouth for a period of 7–10 days after the operation; we explain that he or she will not be hungry because we will be providing parenteral nutrition. After 7 days from the procedure, we look at the perineum of the patient. If everything looks well and it seems to be healing nicely, we let them eat. On the other hand, if we have any doubts or we see dehiscences of 1, 2, 3, or 4 sutures, either in the anoplasty, in the perineum, or in the posterior sagittal incision, we continue the period of fasting for 2 or 3 more days, take the patient to the operating room, and resuture the dehiscent areas. Very rarely, we have patients that suffer from a complete dehiscence of the anoplasty without a colostomy. In those cases, we perform a colostomy and wait until the wound is healed, not less than 3 months, in order to reoperate.

Patients who underwent a posterior sagittal anorectoplasty in addition to a laparotomy usually start having po feeds 2–4 days after the operation. That period of time depends very much on the degree of ileus that the patient suffers from, which is related with the manipulation of the bowel during the laparotomy. Sometimes, we operate on patients who had previous multiple operations, and we spend long periods of time in the operating room taking down all the peritoneal adhesions. The longest operation that we performed so far, nonstop, has been 18 h in a patient with a cloacal exstrophy in which we were able to repair the rectal component, the vagina, and the urinary tract. Those patients obviously would remain with nothing by mouth for longer periods of time because they have a prolonged ileus. We followed the general guidelines that most surgeons follow-up after complicated laparotomies.

Babies subjected to long operations (longer than 6 h) always go to the intensive care unit. We have seen a tendency for them to suffer from respiratory arrest postoperatively.

Occasionally, we operate on patients that came to us with a loop colostomy. As we previously discussed in the chapter of colostomies, some loop colostomies are totally diverting, and we see that the entire stool goes into the stoma bag. However, when those loop colostomies retract a little bit, they pass stool into the distal bowel. When that happens, after the operation, to avoid contamination, there are several maneuvers that may prevent fecal contamination. One can be the introduction of a Foley catheter in the distal colonic limb, with the balloon inflated for several days, to avoid the passing of stool. Another one is to place a purse string suture in the distal stoma with a heavy, long-term, absorbable suture to prevent the spillage of stool into the distal limb.

We do not restrain the movements of our patients. We do not tie them to the bed. We do not keep the legs together. We let them walk around and move in any way they want. However, we encourage the mother to use a double diaper, to serve as a cushion for the bottom. Also, we prevent the patients from jumping and sitting in a rough way after the operation. Because the posterior approach is basically painless, the patients start jumping around, and sometimes they injure themselves. We keep the double diaper for 1 month. We like to use antibiotic ointment on the posterior sagittal incision, the anoplasty, and the area of the genitalia, in cases of female malformations. However, we use this ointment only for 5 days, because we have seen that after that, the patient has a tendency to suffer from fungus infection in the perineum.

We do not believe that the urine contributes to producing dehiscences. In female babies, with a rectovestibular fistula or rectovaginal fistula, we do not leave a Foley catheter. In cloaca patients, the type of urinary diversion that we use postoperatively depends on the type of cloaca that the patient has (see Chap.​ 16). We leave a Foley catheter for 2 weeks in a case of a posterior sagittal anorectovaginourethroplasty and total urogenital mobilization with a short common channel. When the patient has a common channel longer than 3 cm and we enter into the abdomen, we prefer to leave a suprapubic tube particularly if we believe that the patient will be able to urinate normally, before 3 months after the operation. When the patient has severe kidney damage, hydronephrosis, megaureters, and complex malformations and we believe that it is going to take longer than 3 months for them to pass urine normally, we prefer to leave a vesicostomy.

In male patients with rectourinary fistulas, we leave a Foley catheter for 1 week. After a week, the patient comes to the clinic, our nurses pull the catheter out early in the morning and ask the parents to take the baby to walk around and drink a lot of fluids, to be sure that the patient is passing urine normally before sending him home. Occasionally, the patient shows signs consistent with burning of the urethra during the voiding episodes; we encourage them to take more fluids and eventually the symptom disappears. It is extremely unusual to see patients in urinary retention after a technically correct posterior sagittal operation. However, if the patient has a poor sacrum, tethered cord, and a very high malformation, we can anticipate that, occasionally, they may have urinary retention. Under those circumstances, we leave the Foley catheter for a few more days and remove it again. If we already know that the patient has neurogenic bladder, then sometimes we leave a suprapubic tube, in order for our colleague urologists to evaluate the bladder postoperatively with a urodynamic study.

Prior to the repair of anorectal malformations, the parents of our children receive a piece of paper describing our protocol of anal dilatations (Fig. 18.1).

We encourage the parents of our patients to read the protocol and memorize it, before coming to the clinic 2 weeks after our procedure.

We have been in national and international meetings, in which some surgeons question the need to perform anal dilatations in patients with anorectal malformations. In fact, some surgeons have expressed a negative impression about the use of dilatations, because of the potential psychological trauma produced in the children, due to the pain that we provoke with these dilatations.