Research report: Successful non-operative management of wound dehiscence after PSARP: case report

Surgeons in Saudi Arabia report that a baby girl who developed a serious wound complication after corrective surgery for an anorectal malformation healed completely without any further operation, thanks to a conservative wound-care regimen that combined silver-containing dressings with a topical purified hemoglobin spray. The case, published in Frontiers in Pediatrics, describes how a multidisciplinary team preserved the function of the reconstructed anus despite the parents’ refusal of the surgical intervention that is usually recommended in such situations.

The child was born at 36 weeks and 6 days of gestation by elective cesarean section to a 41-year-old mother with gestational diabetes and four previous cesarean deliveries. She weighed 2.9 kilograms at birth. Examination after birth revealed collodion skin, an extra digit on the left hand, and a rectoperineal fistula, a type of anorectal malformation in which the rectum abnormally connects to the perineal skin.

The infant was discharged on the sixth day of life, and her mother continued the dilations at home with regular clinic follow-up, allowing gradual advancement of the dilator sizes in anticipation of the repair. Other features of the VACTERL spectrum were managed by the relevant specialty services.

At four months of age, weighing 6.6 kilograms, the child was admitted electively for a formal posterior sagittal anorectoplasty, or PSARP, the most common surgical repair for anorectal malformations. The operation, performed under prophylactic antibiotics with amoxicillin-clavulanic acid and metronidazole, proceeded smoothly without complications.

The recovery did not remain uneventful. On the third postoperative day, the wound showed mild redness around the perineal body, but the neoanus was intact and no discharge was present. By the fifth day, however, the team noted a superficial dehiscence of approximately 0.5 centimeters at the perineal body, accompanied by foul-smelling discharge and spontaneous detachment of the Monocryl sutures. The authors suggest this suture detachment might indicate a regional allergic reaction to the suture material, noting that rare skin reactions to poliglecaprone 25 and other suture types have been documented in adults. The mother also reported that her own cesarean scar had dehisced in the first week after her surgery, a family history the authors considered potentially relevant.

Wound dehiscence is a common early complication after PSARP. It can be classified as superficial, involving only the anocutaneous junction, or deep, involving disruption of the repaired muscles. Its pathogenesis is not fully established, but bacterial infection and reduced tissue perfusion have been proposed as contributing factors. Risk factors discussed in the literature include the type of procedure, gender, age at repair, prematurity, birth weight, the specific type of malformation, associated anomalies, and antibiotic use. Notably, the presence of cardiac anomalies has been identified as a significant risk factor for impaired wound healing. A divided colostomy is generally considered protective, because it prevents fecal bacteria from contaminating the perineal wound, and dehiscence is less likely after multi-staged repairs with a stoma.

When the dehiscence appeared, the team formed a multidisciplinary group that included wound-care specialists, dietitians, clinical pharmacologists, dermatologists, and general pediatricians. Total parenteral nutrition was initiated through a peripherally inserted central catheter line, and dermatology treated the infant’s diaper rash. The parents were counseled about colostomy creation, which was recommended to protect sphincter function, prevent possible future incontinence, and control infection. They strongly refused the operation, leaving the team to pursue an entirely non-operative path.

That path centered on meticulous local wound care. The hemoglobin spray is designed to accelerate healing by increasing oxygenation at the wound surface through facilitated diffusion, and it has previously been reported to speed healing of burns, venous ulcers, diabetic foot ulcers, infected post-traumatic wounds, and postoperative wounds. It may also promote collagen synthesis by supporting the hydroxylation of proline and lysine, contributing to a stable collagen structure. The silver dressing releases ionic silver when exposed to wound exudate, providing broad-spectrum antimicrobial activity by disrupting microbial cell membranes, inhibiting metabolic enzymes, and interfering with DNA replication, while its absorbent fiber structure manages exudate and maintains dressing integrity.

The response was marked. Anal dilation of the neoanus resumed one month after surgery, with good contractility and stool continence observed. The child was discharged five weeks after the operation. At a seven-week clinic visit she had no active complaints, was passing bowel movements regularly with preserved anal function and no incontinence, and the wound was healing well. At nine months of age, her mother reported episodes of constipation treated with a glycerin suppository, but the neoanus remained continent. The child has continued annual follow-up, reached two years of age without symptoms, and began toilet training without issues.

The authors caution that this is a single case and that evidence for conservative management of post-PSARP wound dehiscence in infants remains limited. Data on purified hemoglobin spray in children are particularly sparse; the first published pediatric study reported its effectiveness in second-degree burns. The authors conclude that conservative, multidisciplinary management may be a feasible option for selected cases of superficial dehiscence after PSARP when the neoanus is intact and the patient is clinically stable, and they emphasize that further pediatric studies are needed to confirm the safety and effectiveness of topical hemoglobin spray with advanced dressings for post-PSARP wound complications.

Subject of Research: Conservative management of wound dehiscence after posterior sagittal anorectoplasty for anorectal malformation

Article Title: Successful non-operative management of wound dehiscence after PSARP: case report

Article References: Almabyouq, F., Abualsaud, Z. F., & Alsharrah, W. S. (2026). Successful non-operative management of wound dehiscence after PSARP: case report. Frontiers in Pediatrics, 14, Article 1933431. https://doi.org/10.3389/fped.2026.1933431

Image Credits: AI Generated

DOI: 10.3389/fped.2026.1933431

Keywords: anorectal malformation, PSARP, wound dehiscence, hemoglobin spray, silver dressing, conservative management, pediatric surgery, VACTERL association, neoanus, case report, wound healing, colostomy