Jordan Journal of Agricultural Sciences, Volume 9, No.

2 2013

Surgical Repair of Atresia Ani (imperforate anus) in Newborn Kids and Lambs
Mousa Husein Daradka 1

ABSTRACT

Atresia ani is a congenital defect describes absence of a normal anal opening. It is fatal unless surgical correction
is carried out to provide anal opening. In female, the rectum may break through vagina forming a rectovaginal
fistula permitting defecation via the vulva. Surgical treatment of atresia ani is indicated to save the animal life
and to improve body weight gain. Ten kids and eight lambs suffering from atresia ani referred to the veterinary
health center at the Jordan University of Science and Technology in the period of 2004-2009 suffering from
atresia ani. Clinical examination and ultrasonography confirmed atresia ani without any other intestinal
congenital deformities. Affected animals were subjected to surgical anal reconstruction following animal casting,
site preparation and analgesia. A circular perineal skin tissue was excised to explore the pelvic cavity associated
with blunt dissection of the perineal region exposing the blind cull- de- sac of the rectum. The blind rectum
segment was opened and the meconium was evacuated. Full thickness rectum and was secured using simple
interrupted stiches. Anal reconstruction proved successfully for all treated kids and lambs. The new stoma
provides a permanent patent orifice for normal passage of feces until the age of slaughter. This surgery was
legitimate, considering the high incidence of atresia ani, simple, economic, and lifesaving surgical technique.
Anal reconstruction in affected animal is an obligatory surgery rather than alternative euthanasia. Anal
reconstruction increases body weight gain and decreases the economic loss in the small ruminant herd industry
due to atresia ani.

Keywords: Kids, Lambs, Atresia Ani, Conginital, Surgery, Reconstruction.

INTRODUCTION urogenital membrane ventrally. The membranes

subsequently disintegrate in normal development. The
The rectum is formed when a mesenchyme partition cranial part of the anal canal (most of the canal) is
(urorectal septum) divides the cloaca into dorsal and formed with the rectum; this part of the anal canal is
ventral chambers. The dorsal chamber, which is lined by a mucosal epithelium derived from endoderm.
continuous with the hindgut, becomes the rectum and The caudal part of the anal canal (caudal to the adult
most of the anal canal. The ventral chamber (the anocutaneous line) is lined by stratified squamous
urogenital sinus) is continuous with the allantois. The epithelium. It forms tissue surrounding the anal
urorectal septum grow caudally and divides the cloacal membrane grows caudally creating a depression called
membrane into an anal membrane dorsally and a the proctodeum; when the anal membrane degenerates,
the proctodeum becomes incorporated into the anal canal
1
Department of Veterinary Clinical Sciences, Faculty of
Veterinary Medicine, Jordan University of Science and
(McGeady et al., 2006).
Technology, Irbid P.O.Box 3030 , Jordan By entering the pelvis, the descending colon becomes the
daradka @just.edu.jo
Received on 4/9/2011 and Accepted for Publication on rectum, which passes caudally as the most dorsal organ of the
24/9/2012.

© 2013 DAR Publishers/University of Jordan. All Rights Reserved.

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Surgical Repair of… Mousa Husein Daradka

pelvic viscera. Most of the rectum is suspended by the segment of intestine terminates in a blind end and the
mesorectum, but the terminal part is totally retroperitoneal. distal segment beings similarly with two ends being
The retroperitoneal space is filled with soft tissue rich in fat joined by a fibrous cord devoid of lumen. Type IIIa
covers the anus. The short anal canal is the terminal part of atresia is similar to type II except that the proximal and
the alimentary canal, which opens to the outside with the the distal intestinal segments blind ends are completely
anus. The external and internal anal sphincters control the separated and there is a mesenteric defect corresponding
anus. External sphincter is striated muscle arising from the to the missing segment of intestine. Animals with type
caudal vertebrae while the internal sphincter consists of IIIb atresia have a coiled distal segment of intestine.
smooth muscle and is a modification of the circular layer of Type IV atresia involves multiple sites of atresia (Kilic
the muscle coat of the rectum. At the anus mucosa, the and Sarierler 2004; Rahal et al. 2007).
columnar intestinal epithelium is replaced by the stratified Atresia ani is fatal affection to the male unless
epithelium of the skin (Konig and Liebich, 2006). surgical correction is carried out to provide anal
The major blood supply to the rectum is cranial rectal opening, in female rectum frequently break through to
artery, a branch of the caudal mesenteric artery, which vagina forming a rectovaginal fistula and thus permit
runs within the mesentery and over the dorsal rectal defecation via the vulva (Norrish and Rennie, 1968).
wall. The anal region is supplied by branches from the Atresia ani was reported as a possible genetic defect in
caudal rectal artery, an indirect branch of the vaginal Swedish Highland Cattle, Holsteins, and other breeds.
artery of the female or prostatic artery of males. The Atresia ani is the most common intestinal defect in sheep and
cranial rectal veins lead to the portal circulation through is believed to be due to an autosomal recessive gene. In a
the mesenteric trunk, while those from the anal region series of 64 cases of atresia ani in sheep, 42 (62%) were
drain into internal pudendal veins. associated with defects of other body systems, especially the
One or more caudal rectal nerves (S4-5) run between the urogenital and musculoskeletal systems (Newman et al.1999;
rectum and the internal face of the pelvic diaphragm. They Ghanem et al., 2004; Kiliç and Sarierler 2004; Loynachan et
are composed of somatic motor fibers destined for the pelvic al. 2006; Rahman et al. 2006; Magda and Youssef 2007;
diaphragm and voluntary anal muscles (Dyce et al., 1987). Bademkıran 2009).
Congenital defects, abnormalities of structure or Affected animals may survive for up to 10 days and
function present at birth, may be caused by genetic or can be identified by their depression, anorexia, colic,
environmental factors, or a combination of both; in many marked gradual abdominal distension and lack of feces
cases, the causes are unknown (Servet et al., 2009). (Radostitis et al., 2000).
The term atresia describes congenital occlusion of Atresia ani should be treated by surgical operation to
the lumen of the digestive tract. Failure of the anal solve the problem, improve body weight gain, and reduce
membrane to break down during the development gives economic loss caused by this defect (Servet et al., 2009).
rise to the condition termed imperforated anus and some Anal reconstruction in small ruminant is not
times termed as atresia ani (McGeady et al., 2006). routinely attempted in veterinary practice, this study
There are four major types of intestinal atresia. Type aimed to determine the efficacy of anal reconstruction in
I atresia is a mucosal blockage within the intestinal improving survival rate, health and bodyweight gain of
lumen. In animals with type II atresia, the proximal affected small ruminants.

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Jordan Journal of Agricultural Sciences, Volume 9, No.2 2013

Materials and Methods (Lidocaine injection, 50 ml, 2%, Rotexmedica, Trittau,

Animals Germany) was infiltred around the anal scar (Fig: 1).
Ten mixed breed newborn kids (7 males and 3 females) Anal reconstruction:
and eight newborn lambs (6 male and 2 female) weighing, Following the procedure of Frank (1964), atresia ani was
3-5 kg (mean, 4 kg) aged 3-8 days , none of them were treated by excision of a circular piece of skin around anal
twins, from north Jordan flocks. They were referred to scar. The blind ended rectum was exteriorized after blunt
veterinary health center in Jordan University of Science and dissection of the perineal canal (Fig: 2). Then, the blind end
Technology in the period of 2004 to 2009. These animals of the rectum was retracted caudally, and fixed to the perineal
were physically examined by a standard examination skin. Four stay sutures were placed dorsally, ventrally and
procedure. Diagnosis was obvious when the anus was bilaterally using 2-0 absorbable suture material
absent. In these animals, there was a pronounced protrusion (MONOCRYL, violet, size 2-0, monofilament absorbable
of the perineal region by deep palpation of abdomen. suture, rounded 1/2 circle, ETHICON, Johnson Company,
Diagnosis was confirmed using ultrasonography. USA). These sutures were performed in simple interrupted
Surgical procedure pattern holding sero-mascular layer of rectum to the perineal
Anal reconstruction was the recommended treatment. skin. Numerous sutures were placed all around the rectum
Animals were sedated using 2% Xylazine (Xyla-Ject, 50 using 2-0 absorbable suture material in simple interrupted
ml, 2%, the Egyptian Co. for chemicals and pattern holding full thickness layer of rectum with full
pharmaceuticals (ADWIA), Egypt) at doses 0.05 mg/kg, thickness of perineal skin (Fig: 3). This was to ensure good
IM (Magda and Youssef 2007). On surgical table, and fully contact between the rectum and the perineal skin.
animals were casted in sternal recumbency and both hind Then, the blind end of the rectum was incised to evacuate the
limbs were secured. Perineal area was shaved; cleaned, content of the lumen. Meconium was evacuated to allow
scrubbed and standard surgical site preparation was good exposure of surgical site (Fig: 4).
performed. Local analgesia using Lidocaine HCl 2%

Figure 1: Pre-operative photograph of lamb

perineal area showing where the anus would
normally be located and the local infiltration
of lidocaine HCL.

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Figure 2: Intra-operative photograph of lamb

perineal area showing bluntly dissected pelvic
canal, the rectum retracted in caudal
position. (A) The rectum, (B) the
mesorectum, (C) perineal fat.

Figure 3: Intra-operative photograph of

lamb perineal area showing the retracted
rectum during rectopexy to the pelvic
diaphragm.

Figure 4: Intra-operative photograph of

lamb perineal area showing the incised
blind rectum to evacuate meconium
producing a patent anal stoma.

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Jordan Journal of Agricultural Sciences, Volume 9, No.2 2013

Figure 5: Pre-operative sonograph of lamb

abdomen showing the meconium impacted
gastrointestinal tract.

Postoperative care spinal cord.

A thorough follow up physical examination was Anal reconstruction as a treatment of atresia ani by
performed daily for fourteen days to evaluate wound excision of a circular piece of skin at bulging perineal
healing and improvement of animal health. Animals area facilitated dissection of the blind end of the rectum.
were monitored for six months (age of slaughter) to It fixed the rectum by stay sutures (rectopexy) at the site
evaluate body weight gain. where the anus is normally located providing a
The following antibiotic and anti-inflammatory permanent functional anal stoma. Blunt dissection saved
regime was given for all animals. all adjucent anal muscels and strucures. This gave a clear
• Penicillin and streptomycin (pen-strep, 100 ml, surgical field and good access to fix the rectum to
Norbrook Laboratories Limited Newry, Co): 10,000- perineal skin. Body weight increased by 3 kg per month
30,000 IU/kg, IM, Bid for 5 days. untill the age of slaughter (six months).
• Gentamycin 5% (Alfamycin, 100 ml, In all animals, anal reconstruction was performed
AlfaMedic): 3-6 mg/kg, IV, Bid for 5 days. satisfactory. After postoperative period, all animal's wounds
• Flunixine meglumine (Finadyne, 50 ml, 50 fully healed without any significant complications. All
mg/ml, Schering Plough Animal Health): 1.1 mg/kg, IV animals were able to nurse their dams. No clinical side
daily for 10 days. effects were observed after surgery except mild sign of
Results digestive discomfort in three treated animals without any
In addition to clinical examination, ultrasound of the need for further treatment.
perineum (rectal and vaginal areas) was useful to Defecation was normal soon after surgery. Fecal
confirm atresia ani diagnosis. Ultrasonography revealed passage was achieved without any need of spescific care
the meconium filled intestine loops (Fig: 5). It also or interference which improved animal health and body
determined the distance between a meconium-filled weight gain. Full function anal stoma was achieved after
distal rectum and the perineum. Ultrasound could wound healing at about one month post operative. The
determine any anomalies of the urinary tract or the diameter of new artificial opening enlarged by time. It

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Surgical Repair of… Mousa Husein Daradka

was sufficent to by pass the feces without any and treatment of atresia ani after birth. Some affected
compliction or straining despite the abcence of external females grow normally and may contribute in herd
and internal anal sphincter functions. reproduction, keeping the high incidence of atresia ani.
In this study, all animals were not considered for
Discussion breeding and were slaughtered at six months of age.
Atresia ani has been reported to be a heritable Four major types (I, II, IIIa, IIIb and IV) of intestinal
condition in pigs and calves (Kilic et al. 2004). Based on atresia have been described involving different intestinal
this all treated animals were not considered for breeding; segments (Kilic and Sarierler 2004; Rahal et al. 2007).
they were slaughtered at six months of age. A genetic The animals presented in this study suffered from atresia
basis has been documented for some cases of atresia ani, ani only without any other intestinal anomaly.
but the specific cause in sporadic cases in domestic Anal reconstruction was relatively painless using
species and humans is not always known (Johnson et sedation and local anesthesia and was not invasive surgery.
al.1980; Newman et al.1999). Mild signs of digestive discomfort were detected in three
Some authors Johnson et al. (1983), Leipold (1986) treated animals, as postoperative complications can occur,
and Noh et al. (2003) reported that the most congenital including fecal incontinence and colonic atony secondary to
anomalies of digestive system observed in calves were prolonged preoperative distension (Maria and Karen, 2005).
atresia ani and atresia recti. Besides, the anomalies of In the present study during suckling period the feces was soft
urinary system such as renal agenesis, polycystic kidney and normally excreted, once the newborn animal changed
and skeleton system such as cocygeal or sacral vertebral diet a normal pellet like feces was excreted and no
agenesis were observed at the same time in calves. postoperative complications were found. This finding
However, in this study animals were suffering from showed that the new anal orifice increased in size with age
atresia ani only and were treated by anal reconstruction. and was able to excrete feces in spite of absence of anal
Atresia ani is a fatal affection to the male unless sphincters.
surgical intervention occurs to provide new anal stoma. It could be concluded that anal reconstruction is the
In some females, fecal pressure result in rectum break only treatment for atresia ani in newborn animals. It is
through vagina forming a rectovaginal fistula and thus recommended in ruminants as it saves life of animal,
permit defecation via vulva, therefore affected female improves body weight gain and reduces herd economical
does not require a further care or surgical correction, and loss. The operation proved to be painless and economic.
may not be identified (Norrish and Rennie, 1968). In In addition, the future breeding of surgically treated
present study, treated females did not develop animals should be discouraged.
rectovaginal fistula, this was because of early diagnosis

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‫…‪Surgical Repair of‬‬ ‫‪Mousa Husein Daradka‬‬

‫ﺇﺼﻼﺡ ﺠﺭﺍﺤﻲ ﻟﻔﺘﺤﺔ ﺍﻟﺸﺭﺝ ﻋﻨﺩ ﺍﻟﺠﺩﻴﺎﻥ ﻭﺍﻟﺤﻤﻼﻥ ﺍﻟﻤﻭﻟﻭﺩﺓ ﺤﺩﻴﺜﺎ‬

‫‪1‬‬
‫ﻤﻭﺴﻰ ﺤﺴﻴﻥ ﺩﺭﺍﺩﻜﺔ‬

‫ﻤﻠﺨـﺹ‬

‫ﻋﺩﻡ ﺘﺨﻠﻕ ﻓﺘﺤﺔ ﺍﻟﺸﺭﺝ ﻫﻭ ﻤﺭﺽ ﻭﺭﺍﺜﻲ ﻴﺘﻤﺜل ﺒﻌﺩﻡ ﻭﺠﻭﺩ ﻓﺘﺤﺔ ﺸﺭﺝ ﻁﺒﻴﻌﻴﺔ‪ ،‬ﻭﻴﻌﺩ ﺇﺼﺎﺒﺔ ﻗﺎﺘﻠﺔ ﻓﻲ ﺍﻟﺫﻜﻭﺭ ﻓﻲ ﺤﺎل‬
‫ﻋﺩﻡ ﻤﻌﺎﻟﺠﺘﻬﺎ ‪ ،‬ﺃﻤﺎ ﻓﻲ ﺍﻹﻨﺎﺙ؛ ﻓﺈﻨﻪ ﻋﺎﺩﺓ ﻤﺎ ﻴﻔﺘﺢ ﺍﻟﺸﺭﺝ ﻋﻠﻰ ﺍﻟﻤﻬﺒل ﻤﻥ ﻀﻐﻁ ﺍﻟﻔﻀﻼﺕ ﻭﻴﺘﻡ ﺍﻹﺨﺭﺍﺝ ﻤﻥ ﻓﺘﺤﺔ‬
‫ﺍﻟﻤﻬﺒل‪ .‬ﺇﻥ ﻤﻌﺎﻟﺠﺔ ﻫﺫﻩ ﺍﻹﺼﺎﺒﺔ ﻀﺭﻭﺭﻴﺔ ﻭﺫﻟﻙ ﻹﻨﻘﺎﺫ ﺤﻴﺎﺓ ﺍﻟﺤﻴﻭﺍﻥ ﺃﻭﻻ ﺜﻡ ﻟﺘﺤﺴﻴﻥ ﻭﺯﻴﺎﺩﺓ ﻭﺯﻨﻪ ‪ .‬ﺘﻬﺩﻑ ﺍﻟﺩﺭﺍﺴﺔ‬
‫ﺇﻟﻰ ﺘﺤﺩﻴﺩ ﻓﻌﺎﻟﻴﺔ ﺍﻋﺎﺩﺓ ﺒﻨﺎﺀ ﻓﺘﺤﺔ ﺍﻟﺸﺭﺝ ﺠﺭﺍﺤﻴﺎ ﻟﺘﺤﺴﻴﻥ ﺍﻟﻭﻀﻊ ﺍﻟﺼﺤﻲ ﻟﻠﺤﻴﻭﺍﻨﺎﺕ ﺍﻟﻤﺼﺎﺒﺔ ﺒﻌﺩﻡ ﺘﺨﻠﻕ ﻓﺘﺤﺔ ﺍﻟﺸﺭﺝ‬
‫ﻭﺍﻤﻜﺎﻨﻴﺔ ﺒﻘﺎﺌﻬﺎ ﺤﻴﺔ‪.‬‬
‫ﻟﻘﺩ ﺘﻡ ﺍﺴﺘﻘﺒﺎل ﻋﺸﺭﺓ ﻤﻥ ﺍﻟﺠﺩﻴﺎﻥ ﻭﺜﻤﺎﻨﻴﺔ ﻤﻥ ﺍﻟﺤﻤﻼﻥ ﻓﻲ ﺍﻷﻋﻭﺍﻡ ‪ 2009 -2004‬ﻓﻲ ﺍﻟﻤﺭﻜﺯ ﺍﻟﺼﺤﻲ ﺍﻟﺒﻴﻁﺭﻱ ﻓﻲ‬
‫ﺠﺎﻤﻌﺔ ﺍﻟﻌﻠﻭﻡ ﻭﺍﻟﺘﻜﻨﻭﻟﻭﺠﻴﺎ‪ ،‬ﺤﻴﺙ ﺘﻡ ﺇﺠﺭﺍﺀ ﺍﻟﻔﺤﻭﺼﺎﺕ ﺍﻟﺴﺭﻴﺭﻴﺔ ﻟﻬﺫﻩ ﺍﻟﺤﻴﻭﺍﻨﺎﺕ ﻭﺍﺴﺘﺨﺩﺍﻡ ﺠﻬﺎﺯ ﺍﻟﺴﻭﻨﺎﺭ‬
‫)ﺍﻷﻟﺘﺭﺍﺴﺎﻭﻨﺩ(‪.‬‬
‫ﻭﺒﻌﺩ ﺍﻟﺘﺄﻜﺩ ﻤﻥ ﺇﺼﺎﺒﺔ ﻫﺫﻩ ﺍﻟﺤﻴﻭﺍﻨﺎﺕ ﺒﻌﺩﻡ ﺘﺨﻠﻕ ﻓﺘﺤﺔ ﺍﻟﺸﺭﺝ ﻤﻥ ﺩﻭﻥ ﻭﺠﻭﺩ ﻋﻴﻭﺏ ﺨﻠﻘﻴﺔ ﺃﺨﺭﻯ‪ ،‬ﺘﻡ ﺇﺠﺭﺍﺀ ﻋﻤﻠﻴﺔ‬
‫ﺇﻋﺎﺩﺓ ﻟﺒﻨﺎﺀ ﻓﺘﺤﺔ ﺍﻟﺸﺭﺝ‪ .‬ﻭﻜﺎﻨﺕ ﻜﺎﻵﺘﻲ ‪:‬‬
‫‪ .1‬ﺘﻡ ﺘﻨﻅﻴﻑ ﺍﻟﻤﻨﻁﻘﺔ ﺤﻭل ﺍﻟﻨﺩﺒﺔ ﺍﻟﺸﺭﺠﻴﺔ ﻭﺤﻼﻗﺘﻬﺎ ﻭﺘﻌﻘﻴﻤﻬﺎ ﺒﺎﻟﻁﺭﻕ ﺍﻻﻋﺘﻴﺎﺩﻴﺔ‪.‬‬
‫‪ .2‬ﺘﻡ ﻗﺹ ﻗﻁﻌﺔ ﺩﺍﺌﺭﻴﺔ ﺼﻐﻴﺭﺓ ﻤﻥ ﺍﻟﺠﻠﺩ ﺤﻭل ﺍﻟﻨﺩﺒﺔ ﺍﻟﺸﺭﺤﻴﺔ ‪.‬‬
‫‪ .3‬ﺘﻡ ﺴﺤﺏ ﺍﻟﻘﻁﻌﺔ ﺍﻟﺠﻠﺩﻴﺔ ﻭﻓﺘﺤﺔ ﺍﻟﺸﺭﺝ ﺍﻟﻤﻐﻠﻘﺔ ﻟﻠﺨﺎﺭﺝ‪ .‬ﻭﺘﻡ ﺘﻔﻔﻜﻴﻙ ﻓﺘﺤﺔ ﺍﻟﺸﺭﺝ ﺍﻟﻤﻐﻠﻘﺔ ﺒﺎﻟﻴﺩ‪.‬‬
‫‪ .4‬ﺘﻡ ﺨﻴﺎﻁﺔ ﻓﺘﺤﺔ ﺍﻟﺸﺭﺝ ﻋﻠﻰ ﺍﻟﺠﻠﺩ ﻋﻠﻰ ﻨﺤﻭ ﺩﺍﺌﺭﻱ‪ .‬ﻓﻘﺩ ﺘﻡ ﻭﻀﻊ ‪ 4‬ﻏﺭﺯ ﺃﺴﺎﺴﻴﺔ ﻓﻲ ﺍﻷﻋﻠﻰ ﻭﺍﻷﺴﻔل ﻭﻋﻠﻰ‬
‫ﺍﻟﺠﺎﻨﺒﻴﻥ ﻭﺘﻡ ﺘﻌﺯﻴﺯ ﺍﻟﻐﺭﺯ ﺍﻷﺭﺒﻌﺔ ﺒﻐﺭﺯ ﺃﺨﺭﻯ ﺤﻭل ﻤﻨﻁﻘﺔ ﺍﻟﺠﺭﺡ‪.‬‬
‫‪ .5‬ﻓﺘﺤﺕ ﻓﺘﺤﺔ ﺍﻟﺸﺭﺝ ﺍﻟﻤﻐﻠﻘﺔ ﻓﺘﺩﻓﻘﺕ ﻤﻨﻬﺎ ﻓﻀﻼﺕ ﺍﻟﺤﻴﻭﺍﻨﺎﺕ ﺍﻷﻭﻟﻴﺔ‪.‬‬
‫ﻜﺎﻨﺕ ﺍﻟﻌﻤﻠﻴﺎﺕ ﺠﻤﻴﻌﻬﺎ ﻨﺎﺠﺤﺔ ﻭﺃﻋﻁﺕ ﺍﻟﻔﺘﺤﺔ ﺍﻟﺠﺩﻴﺩﺓ ﻓﺘﺤﺔ ﺸﺭﺝ ﺩﺍﺌﻤﺔ ﻭﻓﻌﺎﻟﺔ‪ .‬ﺘﻌﺩ ﺍﻟﻌﻤﻠﻴﺔ ﺇﺠﺒﺎﺭﻴﺔ ﻷﻨﻬﺎ ﺘﻨﻘﺫ ﺤﻴﺎﺓ‬
‫ﺍﻟﺤﻴﻭﺍﻨﺎﺕ ﺍﻟﻤﻭﻟﻭﺩﺓ ﻭﻫﻲ ﻋﻤﻠﻴﺔ ﻗﻠﻴﻠﺔ ﺍﻟﺘﻜﻠﻔﺔ ﻭﺘﺯﻴﺩ ﻤﻥ ﻭﺯﻥ ﺍﻟﺤﻴﻭﺍﻨﺎﺕ ﻭﺒﺫﻟﻙ ﺘﻘﻠل ﺍﻟﺨﺴﺎﺭﺓ ﺍﻻﻗﺘﺼﺎﺩﻴﺔ ﺍﻟﻨﺎﺘﺠﺔ ﻤﻥ‬
‫ﺍﻟﺘﺨﻠﺹ ﻤﻥ ﺍﻟﺤﻴﻭﺍﻨﺎﺕ ﺍﻟﻤﺼﺎﺒﺔ ﻋﻨﺩ ﻭﻻﺩﺘﻬﺎ‪.‬‬
‫ﺍﻟﻜﻠﻤﺎﺕ ﺍﻟﺩﺍﻟﺔ‪ :‬ﻓﺘﺤﺔ ﺍﻟﺸﺭﺝ‪ ،‬ﻤﺭﺽ ﻭﺭﺍﺜﻲ‪ ،‬ﻀﻐﻁ ﺍﻟﻔﻀﻼﺕ‪.‬‬

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‫‪ 1‬ﻗﺴﻡ ﺍﻟﻌﻠﻭﻡ ﺍﻟﺴﺭﻴﺭﻴﺔ ﺍﻟﺒﻴﻁﺭﻴﺔ‪ ،‬ﻜﻠﻴﺔ ﺍﻟﻁﺏ ﺍﻟﺒﻴﻁﺭﻱ‪ ،‬ﺠﺎﻤﻌﺔ ﺍﻟﻌﻠﻭﻡ ﻭﺍﻟﺘﻜﻨﻭﻟﻭﺠﻴﺎ ﺍﻷﺭﺩﻨﻴﺔ‪ ،‬ﺍﺭﺒﺩ‪ ،‬ﺹ‪ .‬ﺏ‪ ،3030 :‬ﺍﻷﺭﺩﻥ‬
‫ﺘﺎﺭﻴﺦ ﺍﺴﺘﻼﻡ ﺍﻟﺒﺤﺙ ‪ 2011/9/4‬ﻭﺘﺎﺭﻴﺦ ﻗﺒﻭﻟﻪ ‪.2012/9/24‬‬

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