Electrical muscle stimulation is a very old medical tool that was early used by our ancestors, the Ancient Egyptians, to treat muscle pain and some diseases [4-7].

The electric catfish of the Nile, also known as “thunder of the Nile,” was depicted in Narmer Palette, an important archaeological artifact from ancient Egypt. This ceremonial palette dates back to approximately 3100 BCE [5,6].

History shows that the Egyptians used to put small catfish over the diseased area to create a tingling sensation to relieve muscle pain or other disorders [5].

From that time, experimental scientific studies started only in the 18^th century by many, such as Luigi Galvani and Alessandro Volta, and continued to evolve through the 19th and 20th centuries [8,9].

Nowadays, Electrical Muscle Stimulation (EMS) is a well-established branch, including different types of electrical stimulation such as TENS (Transcutaneous Electrical Nerve Stimulation), Interferential Current (IFC) Electrical Stimulation, High Voltage Electrical Stimulation, Electrical Muscle Stimulation, Functional Electrical Stimulation, Neuromuscular Electrical Stimulation, Russian Electrical Stimulation, Galvanic Electrical Stimulation, and Faradic Electrical Stimulation [10].

They differ from each other in the type of current [12] as low-voltage current: less than 100 volts, under 1 Hz. High-voltage direct current: extremely short-duration pulse in the range of 300 to 500 volts. Interferential current in the range of 4000 to 4100 Hz, with a net frequency in the interference zone of 80 to 100 Hz, and the power is in the low-voltage range. Medium-frequency current in the range of 2400 to 2500 Hz (Russian type). And finally, low frequency current, utilizing frequencies in the range of 1 to 330 Hz, pulse width from 50 to 300 msec. with a medium range amplitude of 10 to 50 mA.

They are applied in medicine in many conditions such as Pain management, Wound healing, Incontinence, Physical rehabilitation, Atrophy, weight loss, enhance athletic performance, ETC [11-16].

We are using TENS (Transcutaneous Electrical Nerve Stimulation) device, which boasts numerous advantages, including its affordable price between $5 and $9. Its dimensions are (15 cm by 6 cm). It's light in weight (90 g), which enhances its portability, using 3 ordinary batteries of AAA size, producing low-frequency waves of 1-330 Hz, and producing 1-7 volts. The device comes with preset modes that differ from each other in the frequency, amplitude, and duration of the impulse, with a button to increase or decrease the intensity from 0 to 15. We usually use the massage mode in neonates, starting the intensity with 1 and increasing as desired. In older patients, we prefer to use the manipulation mode as it provides a stronger contraction effect. We usually prefer to mark the site of maximum muscle contraction after anesthesia induction. We have acquired several techniques to optimize muscle contraction efficacy. Firstly, it is advisable to refrain from using muscle relaxants. Secondly, moistening the skin with normal saline is beneficial. Thirdly, positioning both ends of the probe as far apart as possible facilitates the propagation of current through the tissues. Finally, ensuring that the probe adheres to the skin for a minimum of three seconds is crucial for achieving proper contractions. Implementing these strategies consistently yields reproducible results with every application.

Intraoperative usage is also feasible by covering the device with a sterile camera cover, then connecting a sterile bipolar probe to it, and then the classic steps of the procedure can be carried out to allocate the anterior and posterior boundaries of the muscle complex.

Furthermore, we observed that in high anomaly patients, usually the muscle contraction is less prominent than in low anomaly patients; this could be attributed to the underdeveloped muscle complex.

Our study demonstrates that a TENS improvised device can provide comparable functional outcomes in terms of sphincter localization in different types of malformation and different age even in neonates where some surgeons prefer to perform the repair. An additional advantage of the improvised device is its affordability, portability, and ease of use, making it particularly suitable for low-resource environments, (Table 2).

However, some limitations should be acknowledged. The sample size is relatively small and multinational study was not done. Future studies are recommended to validate these findings.

Table 2: Comparing between Peña stimulator and our improvised muscle stimulator.