Elmer, Elmer, Elmer, Elmer, Elmer, Elmer, Elmer, Elmer, Elmer, Elmer. All right, good morning, everyone. It's my pleasure to introduce Dr. Belinda Dickie and Dr. Aaron McNamara, who will be giving a special joint surgery and urology grand rounds and update on the colorectal center. Dr. Dickie did her general surgery residency at the University of Alberta, followed by pediatric baccalaureate anomalies and colorectal fellowships and Cincinnati, and then pediatric surgery fellowship at the University of Florida. She then joined faculty at Cincinnati before coming to Boston Children's in 2016, where she's now the co-director of the colorectal and pelvic malformation center. Dr. Aaron McNamara did urology residency at Duke, followed by pediatric urology fellowship at Boston Children's. She then stayed on his faculty in the Zsiosiath director of the colorectal and pelvic malformation center and the co-director of the Spina Bipida Center. They will be speaking on the colorectal and pelvic malformation center, caring for our patients from birth to adulthood. Dr. Dickie and Dr. McNamara, thank you so much for being here with us today. Thank you. I'm going to just share our screen here. Oh, stop here. I'm having it at the beginning. Sorry. We had it all set up, but then we were playing around with it. Sorry, here we go. So thank you for having us speak with you all today. Hester asked us a while ago, and I've been trying to put it off because I hate public speaking. But here we go. So we're going to sort of talk about the inception of our... Start. I am sorry. Our colorectal and pelvic malformation center, which started in about 2016 to 17, we'll talk a little bit about the center itself, some of our cases and innovations, and where we're hoping to go from here. We have no disclosures except that both Erin and I are following in the footsteps that Boston Children's Hospital of huge giants in the field of pediatric surgery and pediatric urology. I have to walk by Dr. Pendran's portrait every day when I walk in, which reminds me of what he has done here, and the multitude of patients that we continue to look after from his legacy. And as well, Dr. McNamara has worked extensively and been mentioned by Dr. Reddick. And both of us feel like we have big shoes to fill, and we hopefully are able to do that in the coming years. The learning objectives for the session today, we're going to talk about the patient population. We see different ways that we do evaluate these anomalies and discuss some of our new innovations that we're trying to push the envelope in this field. So this is a year ago, which is kind of crazy. This was our first sort of Zoom meeting of our Colorectal Center at that time, and we were doing daily check-ins to make sure everyone was okay, and it's hard to imagine that that was a year ago. Funnily enough, we were in the office the other day, and we have these two little baby mascots, which have malone sites, and this was their warning to us on New Year's Eve last year. So once again, quite telling of what this year has been like. But hopefully we can tell you how much we actually enjoy our jobs, and do it with a little bit of humor and a little bit of style. So the Colorectal Palomite Information Center, it was started to sort of integrate the care of these patients. Myself, of course, we are concentrated on the anus and the rectum. Aaron, of course, is concentrated on the urology portion, and the center is to talk about, and what we're going to talk about today is our collaboration together for both systems. Aaron initially came from Buffalo. I was born in Canada, and really it's not that far away from Buffalo, and we both here in Boston Children's Hospital. I have to thank the two people who got me interested in the topic, Dr. Peniel and Dr. Levit, who have trained me and taught me the field. Dr. Schamburger, as brought me here, Dr. Lillahai, has been a great mentor in starting the center here, and talking through cases. And then, of course, Dr. Fuechman, who's our new leader here. With respect to the urology side, Dr. Boer has a long legacy, and we really talked to him about some of the complicated cases as well, and he's mentored us through many of the coicas and extra fee cases. And then, of course, Dr. Strata, now, who is the chief of urology. So, this center itself is known as the colorectal and pelfermac formation in long-term. Everyone in the OR and around the hospital actually knows us as team crab, which actually does have a good ennemonic because it's colorectal and pelvic malformation and peace center. We specialize in taking care of patients with both imperferent anus, coicomalformations, OAS. We do some of the pelvic reconsections for some of the vaginal anomalies, and vaginal agenesis. And we do specifically work with GI with some of the Hirsch-Brung's rectal prolapse and colonic dysmotility orders, and work closely with motility center. We've developed our bowel management program here, which is very successful, and our NPs and nurses have been extremely busy maintaining that program as we continue to grow. We try to provide lifelong care for our kids. We actually see prenatal counseling, and we're able to talk to the moms and dads about the initial diagnosis when it's diagnosed prenatally. We see them as they're born, and then we take them through childhood to adulthood, and hopefully by this point in time they've been able to transition to adult care. But as you can see from some of our cases and how things roll in the OR that we actually do take care of some of the adults later on. You can see in the OR we collaborate with a bunch of different surgical specialties. We play nicely for the most part, but for my end, everybody's afraid of us, because no one wants to deal with the poop. Around the hospital, though, we do have collaborative care with multiple specialties, and this is just a smattering of who we also work with and interact with in and around the hospital. So I have to give credit to these two ladies who actually were phenomenal in starting the center with me, and Erin, Liz Pinacho, who is now our program coordinator, and our Brzella was our initial MP who put her heart and soul into starting and organizing and helping us get everything going. Our patients have grown significantly and almost tripled in number now. These are some of our, at the end of our launch from our program. In 2019, you can see our numbers have consistently grown. And our surgical procedures have also increased throughout the years. This is our 2020 numbers, and we continue to increase the numbers, and we actually haven't slowed down through COVID at all, as we are still doing a majority of our visits via telehealth. Currently, as you saw, we had two people to start that were supporting us. We now have a whole team that works with us. We've added surgeons, urologists, the GI team, gynecology. Our nursing team has grown, and we also have a social worker, and we recently added Dr. Lauren Mednick from the psychology aspect. And so we're going to describe a little bit about our childhood adult. And this is what we want to see. Do you want to watch me grow? And we actually watch our kids grow from childhood to adulthood, and they actually are able to tell their stories to us. And it's what wonderful thing to see. So, Erin's going to now take over and talk about some of our cases and sort of the collaboration and invasions. So, talking about these cases, this is not to go into a lot of detail, but we do want to talk a little bit about the evaluation. And then some of the innovative things that we're doing here in the center for our patients. So, there's five cases. We're going to talk about male and perforated anus, a few cloacal anomaly cases, as well as vaginal agenesis. So, our first case, this is a child with imperfect anus and recto-urinary fistula, and this was a prenatal diagnosis. So, we actually saw the mom in our MFCC. She was a 36-year-old female, G4-P1, seen for a fetal enlarged bladder, and a large cystic structure was seen in the fetal abdomen at the 13-week ultrasound. We then obtained 18 and 28-week gestational ultrasound, and this demonstrated a probable imperfect anus and rect hydrinoprosis. So, you can see that here. This is the prenatal ultrasound done at 28-week gestation. You can see the left kidney, some hydrinoprosis of the right kidney, and then this large pelvic cyst, and this is actually the rectum with layering debris filled with urine and muconium. And we have wonderful radiologists and the whole team in the MFCC that we work with closely to help us identify these patients prenatally so we can meet with families and discuss expectations. So, mom underwent a C-section at 35-week gestation, physical exam confirmed imperfect anus and undisended testicles, and an ostomy was created on day of life number one. And at that time, intradominable testicles were visualized. So, just briefly to talk about the evaluation, newborn imaging for imperfect anus, so we always obtain a plain x-ray. It's very important to obtain renal bladder ultrasound because we can see GU anomalies in 30-50% of patients with aneorectal malformations, as well as a spine ultrasound because spinal anomalies are also very common in this population, as well as avoiding sister urethrogram to identify both the urethra and the urethra. And here we have an example of the VCUG. And you can see the bladder filling and as there's voiding, the rectum is being filled through that fistula. So, further imaging, after the newborn period, as the child grows, are other imaging that we want to do prior to repair. A contrast endoma is important also to evaluate the fistula location of the rectum with relation to the spine, as well as an MRI spine. So, if there were abnormalities seen on the ultrasound, we oftentimes get an MRI of the spine after three months of age to further evaluate, and then also work with our neurosurgery colleagues. And then a contrast enhance ultrasound is something that we've been doing here at the center, and I'll talk about that in the next case. So, for this person, he underwent cystoscopy and p-syp at six months old. We saw a recto-bulb-ar-affishula visualized on cystoscopy. The osmetic breakdown was then six weeks later, and he also underwent a stage fallar Stevens-Burkepathy for bilateral undestandentestials. So, the follow-up for imperfect anus, just really briefly, as this child grows, they'll be continued to follow up for bowel management, because he didn't have the hydrin afrosis and GU anomalies. He'll obtain serial renal bladder ultrasound to follow this. And then, as he grows into toilet training, age will identify any urinary issues. So, this really is something that we follow into childhood and adolescence. So, for our next case, this is going to be a collaicle anomaly. And this was a newborn abdominal distension. So, there were some prenatal findings. It was presumed that this was a collaicle anomaly. There were two vaginocene, two uterai, hydrometrocopal, so a significant abdominal distension, right urinary tract dilation, polyhydramios, as well as presumed pulmonary hypoclasia. Mom underwent a STATC section at 38 weeks gestation, and there was neurologic insult during the delivery, so the child was intubated and started on a cooling protocol, and then transferred to our NICU. This is some prenatal imaging that, again, we had. You can see here the abdomen, as well as the fluid filled vaginas, and the two uterai. And, of course, the concern for the pulmonary hypoplasia. And so, we did obtain some newborn imaging, and really significant, obviously, abdominal distension displacement of all the gas and intestines here. And then, on pelvic ultrasound, you can see these fluid filled cavities, and this was consistent with our prenatal diagnosis and imaging. So, for this child, once they were transferred over here, the hydrometriolpose was drained with a catheter via the common channel, and clean intermittent catheterization was initiated. And this is something that I learned from Dr. Borer. Not every child needs a vasocostomy or a vaginostomy tube, who's born with this hydrometriolpose, and if you're able to drain it with CIC, that would be the preferred method. Osteomy was created on day of life number two, and then we did end up placing a super-pubic catheter. This was done at the bedside in the NICU on day of life number three, when CIC became difficult because of the anatomy. So, again, we have that newborn imaging, the pelvic ultrasound, with the fluid filled vaginas, and then after catheterization, you can see how well this decompresses. And here is a picture of the anatomy. So, with a cloaca, there's a single opening, so we don't see a rectum, and the opening actually was really small, and we weren't even sure where it was, but it was up here, and we were able to see that. And once we started catheterizing, the opening was very clear. So, just briefly to talk about evaluation, some newborn imaging for the cloagal anomaly. Again, renal bladder on the ultrasound. We see G.U. anomalies, and up to 90% of our patients, and final and final, so very important, because final anomalies are used in a majority of these patients. We get a pelvic ultrasound to look at the malaria and structures, and to look for fluid collections. It's important to get the sacral x-rays, and the gastroenteritis, and the gastroenteritis, and the gastroenteritis, and the gastroenteritis, and the gastroenteritis, as well as an echo because of the bacterial association, seeing these patients. As the patients get older, again, an MRI of the spine can be helpful, if abnormalities were seen on ultrasound, or if a child is over three months, and hasn't had spine imaging. But almost all of our cloagal patients do end up getting neurodynamics. We oftentimes don't do neurodynamics pre-operatively, because there have been some studies to show that there's really no difference, pre-operative, and post-operative. But we do continue to follow them as they get older, start toilet training, have issues with incontinence, to see if there are issues at the bladder and sphincter. And then probably most importantly, for our surgical planning, is the cloacogram. So the cloacogram is a study to identify the length of the common channel, of the urethra, the distance to the rectum, as well as the malaria and structures. And so catheters are placed into the different structures for identification. And these are the more traditional ways of doing the cloacogram. So fluoroscopy, as you can see here, also you can use 3D CT, or MRI to obtain some of these measurements, and to see the anatomy. However, these studies require radiation or extra anesthesia. And so working very closely, with our radiology colleagues, we have started using contrast enhanced ultrasound. And this is something that we are using looking at best coerular re-flux. And so we decided to go ahead and use it for this indication, as well. So contrast enhanced ultrasound can be done at the time of the initial cystoscopy and examine under anesthesia. There is no radiation. And the catheters are placed in the bladder, vaginas, and rectum through the mucus fistula. You can see here, then, the comparison of a more traditional cloacogram. And then on the right, you can see what we get with the contrast enhanced ultrasound. And again, so there is no radiation with this study. And here is just a video, show kind of the filling of all the different structures. And we get really good anatomic views with this. And so with our collaboration with radiology, we have been able to publish some papers looking at the use of this in anorectomyl malformations. And so, you know, again, just this highlights the collaboration that we have with departments all over the hospital, working closely together to better the care of our patients. All right, so on to our next case. This is another patient with clinical anomaly, but we are going to highlight the innovative surgical approaches that we have taken here. So this child was born in an outside hospital, transferred care to BCH for evaluation around five months of age. She underwent exam under anesthesia with cystoscopy and vaginascopy, as well as a contrast enhanced ultrasound at that time. And we were able to obtain measurements of the common channel, your withdrawal length, vaginal length, and distance to the rectum. And then we planned for a cloacal repair at six months of age. And here's a picture of her anatomy, and again, the single opening. And you can see also the ostomy that was created right after she was born. So surgical approaches, this is something that's been talked about and debated for years. Traditionally, a total urigenile mobilization was completed, bringing the rectum off of the urigenile sinus, and then mobilizing the complete urigenile sinus down to the perineum. We do still use urigenile mobilization, but more for short channel. There has been associated urinary incontinence with more of the total urigenile mobilization. And what we more commonly do is separation of the rectum and vaginas from the common channel, leaving the common channel as the urethra. And that is very useful, especially for long channels. And so there are different surgical approaches to do these types of surgeries. Of course, you have the P-SARP for the short common channels. Everything can be approached from behind. For the long common channels, oftentimes this would require an open abdominal approach. But what we have done here is combine the P-SARP, as well as a laparoscopic abdominal approach for the long common channels. And so using laparoscopy as a tool to avoid the open abdominal approach. So I'm just going to share this short video, looking at how we do laparoscopy in our clovicle repair. We present here a case of laparoscopic mobilization of pelvic structures for pelvic ports replaced, and the major pelvic structures are easily identified. Rectolasexion is initiated with electrocottery. And caries used to stay outside the rectal wall to preserve intramural blood supply. Although a cottery dissection enables speed in hemostasis, a good portion of this dissection is performed sharply to minimize thermal injury. Dissection was carried out until the rectum narrowed, and it was left in place at its insertion on the posterior vagina. After rectal dissection, attention was turned to Eurogenital separation. Here the bladder and the uterus are easily identified and the peritoneum has already been entered. Again, initial dissection is carried out using cottery, but changes to sharp dissection lower down. The uterus are visualized and protected throughout their course as they enter the trigon. Following dissection, the vagina can be seen mobilized from its surrounding structures. Low Eurogenital dissection, here shown at triple speed, requires patients in meticulous technique. This is the view that can be obtained upon completion with the bladder, both the hereders, and a separate and mobile vagina. With the abdominal mobilization complete, attention is thusly turned to the posterior dissection. The patient has changed a prone position and a midline incision is made. Dissection is carried through the skin and soft tissue, and the first structure encountered is the posterior vagina. The minimal dissection, the low limit of the abdominal dissection is met, who you can see the tonsil entering the abdominal cavity. The rectum is identified posteriorly and proximally to the vagina. With a small amount of dissection, it is possible to finish its mobilization and appreciate the relevant structures and relationships. After the rectum is separated from the vagina, there remain approximately one centimeter of dissection to complete Eurogenital separation, which was performed sharply. After separation is complete, we can identify the urethra, common channel, and residual opening in the common channel. This residual opening is closed in two layers and buttressed with a layer of fat. There were several residual attachments to the vagina, which once divided, allowed adequate length for the vagina to reach the perineum. The rectum had adequate mobility to reach the syringter complex, and the anoplasty was completed in the usual fashion. Special thanks to Tintrell, who is one of our fellows who put this video together and did a lot of work with us on some of this research. That is just an example of how we have started using laparoscopy for the clinical reconstruction. Again, as I said, we have published this. This was a case series of nine patients, but we have actually now done 12 patients and are continuing to follow along. This innovative laparoscopic approach, we can avoid large abdominal incisions for long common channels. The patients actually go home in a reasonable time. Historically, they may have been in a spake of cast or immobilized for a while after these surgeries with these large abdominal incisions. For the long common channel, it is really easy to separate the structures. We have great visualization. The vagina can be brought down without vaginal replacement. Again, historically, if the vagina was unable to come down all the way, a bowel interposition was used. With the short common channel, we can also use laparoscopy. If the rectum is high, we can laparoscopically mobilize the rectum and then do a partial urigenile mobilization versus a minimal vaginal plasty. We are continuing to collect our data for this to look at long-term outcomes and look at the benefits of this approach. The next case is pretty short, but it is another collagal anomaly. This just highlights how we care for our adult patients. The first case is the patient's. She had a 4 cm common channel repaired with laparotomy and the p-SARP approach as an infant. She had care throughout the country with different providers, but she presented then to VCH the 22 years of age with bowel, bladder and gynecology concerns. We are fortunate to have a multidisciplinary approach with coordinated visits with all of our providers in our center, as well as coordinated OR time to address her issues. She and her family were really appreciative of having all of her care in one place after her had been disjointed for so many years. Currently, she is applying to med school and we are really proud of her. We have taken care of several adolescent into adulthood patients. It is really important because for some of these patients, they have just joined to care and have been lost to follow-up and now that they are hearing about our center, they are coming back to seek our multidisciplinary care. Lastly, we are going to talk about a case vaginal egenesis where we used a robotic assisted laparoscopic surgical approach. This is a patient who had primary amenorrhea. She was evaluated by our gynecology team here at Boston Children's Hospital and they obtained a pelvic ultrasound and MRI. You can see here the pelvic ultrasound with the bladder distended and then this fluid-filled structure behind the bladder thought to be the vagina and the uterus. This was all on the right side of the body and here in the MRI, you can see that as well. It was all in the right pelvis, what they could see. There was a vaginal egenesis. Many studies they were able to identify. It was a single uterus and vagina obstructed in the right pelvis, a solitary left kidney, so it falls under one of those ovira or malaria anomalies. They were able to measure 7 centimeters from the perineum to the proximal vagina. She was referred to our center for a surgical pull-through. Again, in these patients, historically, a bowel interposition would have been used to make up that space from the vagina down to the perineum. We were able to complete a robotic assisted vaginal pull-through and we actually used buckle-graft mucosa to augment the vaginal plastic. We actually went in there. There was a small kind of remnant of left-malarion structures. We removed that. We mobilized the uterus and the vagina on the right side and we mobilized this with the robotic approach. Then we did a perineal vaginal placy with buckle-graft and local skin flaps. We used the buckle-graft to augment the vaginal placy and then applied a wound back to the graft, which is something that we're writing up currently. This is an intraoperative picture from the robotic approach. You can see on the right side of the body, the uterus, the vagina, and then this little remnant on the left side that was removed, but a working ovary. Once again, a really great approach to dissect and release the uterus and the vagina and bring it down as far as possible. Then again, using the buckle-graft, here's a picture of where we harvest that from to augment. Actually, a buckle-graft can be used as a full vaginal replacement. It just depends on how much you need. You can use both cheeks to obtain as much graft tissue as needed. Again, these were just five short cases. Not a full evaluation and work-up, but we just wanted to highlight some of the collaboration and some of the innovation that we're doing in our center. Working closely with our MFCC, which is really important for the prenatal diagnosis, talked about innovative imaging with our contrast enhanced ultrasound and working closely with radiology, and especially Mamie Chow and everyone else in radiology. Again, surgical approaches using laparoscopy and robotic approaches to improve care of these patients, as well as the care of the adult patients. Lastly, we're just going to talk briefly about some ongoing projects with center-based care. We could talk probably for hours about things that nursing and social work are working on and QI. We briefly wanted to talk about our patient-family experience, because the reason that we're here is to take care of these patients and these families as they're dealing with these diagnoses. We'll also briefly talk about telehealth and how we've used that over the last year. Dr. Degu will then talk about how we've been trying to establish a transition care program for our adult patients, as well as some of the education and collaboration with simulation that we're doing. So first, just from a patient-family experience. Like I said, this really is motivated by our social work, our psychology, as well as our nursing group in our center. In 2019, we had a family day, which was organized by nursing and social work. This was a day full of education, as well as activities, and just an opportunity for our families to connect. As questions meet other families experiencing the same thing. And this was, I think, really successful. We are hoping to do it in 2020, and of course that was derailed. But going forward, we will be working on bringing our families together and probably using virtual ways of reaching out to our families, because it's been really important, especially through this year staying connected to them. Also, we are working on establishing a family-patient advisory council. And I think this is really important to get the input of our families, of our patients, as we're coming up with educational materials, and other experiences for them to have their input for what they want. And then, as well as working on easily accessible educational content. And this is everything from our Facebook Live and all the things that Mercketing is working with us on, as well as just nursing and social work and psychology, working on handouts and education for our families. And here are some pictures from our family day in 2019, here. And with Dr. Stein and Nephrology, who does a lot of work in our center, as well. And we really had families with kids of all ages come, and it was really great to see them all interact. Next, just briefly to talk about telehealth. I think we're all way more familiar with this now than we were a year ago. But our team really did such a great job over the last year with our QI consultant and working on developing surveys and questionnaires and trying to improve this process for our families. And so they actually put together an abstract and submitted this, understanding the patient and family telehealth experience from a pediatric multidisciplinary colorectal specialist clinic during COVID-19. And this was the QI project in our center, looking at the different aspects of virtual visits. And the results from this are helping our center to better utilize telehealth and meet the needs of our families. Now I'm going to turn it back over to Belinda. She talks about our transition care program. So not that everyone wants to take care of 25, 30-year-olds. But a lot of our patients have no place to go once they reach sort of adulthood. And so when I first got here, that was sort of one of our initiatives was to see if we could actually develop a reliable transition program. So for our patients, one of the things is how it looks. We don't want to make just three openings at the bottom or for boys to openings at the bottom. But we want them to be able to function. We want them to have a good quality of life. And whatever we do to them as infants and children, we don't want to mess what would happen up in adulthood and adult issues. And so this is a great quote from Steve Jobs. It's not just what it looks like and feels like it really is about how it works. And the functionality and quality of life of our patients is becoming more and more evident as you talk to the older children, the young adult lessons and the young adults. So we did a paper on a survey of our older adult patients and looking at their perspective on adult care and how they actually transition. I was fortunate enough to, when quite first got the here, Lori Fischmann was very helpful in developing the survey with us and talking about transition because that's a love of hers as well. And you can see that for the most part, adult patients still are at looked after by the most part, a lot of pediatric providers or family practitioners and the adult providers actually are involved but not really. And the respondents will all say that we go to an adult provider, but they don't know what we're talking about. They don't know what we had done and they don't just understand what's going on. So we partnered with a team over at the BI. It initially started via the gastroenterology route because they have a motility specialist there. And it was fortuitous that Benz and Day has his wife over there was a motility specialist. So I had an in with her and from there we sort of developed the collaboration with the colorectal surgeon, your gynecologist and the urologist there. The thing about transition is we don't want it to be rely on one person or one provider or a relationship between two people one here, one there. We really want it to be something that will sustain several years before after we're all gone. When we talk about transition, we actually start talking about taking care of themselves, the patients in their early adolescent years. And then we set goals and expectations early so that as they reach adulthood and reach independence that they're able to talk about transition. We're trying to do it as a system institution based with somber redundancies, so different providers that there's a succession in providers. And if we the protocols and processes are there, then it would be easier for transition at that point of time. We also have discussed cross training, so having some of the adult colorectal fellows at the BI come over here and do some of our cases here versus some of our providers here seeing how the adult care is as well. The nuances have been sort of away laid by COVID, but we've been talking about doing joint clinics, how often would you do it, where would we do it, and these are all things that we are trying to initiate through COVID and doing it slowly, but the telehealth has actually helped us. So the last thing I want to touch on is sort of the education issues that we're doing. As you saw, we did a family day for patient family education. We also want to educate our trainees, and we also have an interest in helping with education of other surgeons across the world. One of the things about education is, and this is my OCD, our dissection is based on symmetry and preciseness. And so for our fellows and trainees to do the first one on a baby makes me a little bit uncomfortable. And so for my comfort level, and this is totally my comfort level, it would be nice to be able to train the trainees on the simulator first before we're able to have them operate on one of our patients. This is sort of an example of the trainers that have been developed for annual rectal malformations in the past. You can see it's a very crude sort of wooden box. Essentially the rectum is balloon, and so they have you practice dissecting around the balloon and lifting it out. This is the perennial body and the vaginal opening. So part of when I was orienting through here, Steve Fishman introduced me to Peter Weinstock in the simulation center. And we got into talking about how we could create a high fidelity model to train trainees. And our simulation center here is amazing. I know Jill's Alexis is the surgical partner for our training center. She's been very helpful as well, and helping integrate some of this. But it's amazing how when you work with them, they come up with this whole computer model, and it becomes a real model. What our vision was of this was to have a chassis and an interchangeable part where we can make this a girl, a boy, a cloaca, rectal uretho fish, or a vestibular fish shell. And so the chassis is the component that stays permanent, and then you have interchangeable parts that are replaceable that the trainees can practice on, or even surgeons can practice on prior to their case. In the inner workings of it, this was our rectal visstivular model, and you can see that it mimics the anatomy pretty closely. From this computer-generated model, we come up with an actual physical model. And so we're on beta model here, which I'll show you. And you can see the anatomy is actually extremely realistic. The urethra here, vaginal opening, and a vestibular fistula. And for them, I actually do one of these with me, just so that she could also feel the feel of it. The silicone fat has the feeling of silicone fat. These are the parasagial fibers that go down through our dissection. And right here, you can see our center complex, and the rectum sort of poking through in the backside. And as you dissect off, we made this common wall, which in real life, the common wall is about two millimeters. So we actually made this common wall about two millimeters. So you have to practice separating one millimeter to the rectum, one millimeter to the vagina, and try not to make any holes. And they've made it sturdy enough that we can actually complete the anoplasty and put our sutures in and do the starfish-looking thing that we do intraoperatively. The other thing that both Erin and I have a passion for is global health and education. We've, once again, been wail-y by COVID, but we've had several trips now of, we've been to Haiti, and we've been to China. We actually had a trip planned to Mozambique that we had to cancel. But it's been phenomenal and working with different teams across the world, educating, working with the surgeons there, operating with them. In Haiti here, we actually did a laparoscopic coicover repair, which putting together pieces of a laparoscope was the hardest part of the case. In China, we actually ended up doing four laparoscopic coicas. Erin was there for who was able to come. Apollo did a combo or a nurse job plus, plus a ball management nurse, and this is one of the surgeons there. So this is a trip that I went to in Taiwan, and you can see the interest and the education and learning that we were able to provide. So this is, I just want to thank our current team. We have a combination of providers in our clinic that come twice a week, sometimes every week, depending on our need of our patients. For Oak, who is on a little bit of a hiatus, but and Pratima have been phenomenal partners in growing the center together. I have to thank Erin because she and I have started this from the beginning and she's a phenomenal partner, and we both have a very similar vision that our team is to provide an integrated care and for easy access to all aspects of care. And it really has broken down the silos of care for some of these patients, the comments that we get back that, oh, I only have to call one number or go to one clinic visit and everybody's there, makes things so much easier. Dr. Lee has recently joined us and he's added a great perspective on how we can improve some of the efficiencies of our clinic and training of our team. Dr. Marra is our GI, a motility specialist and he's been a great partner in teaching me new things about motility, new drugs, how to manage different things. And you can really see that we actually learn from one another and it's a comment that we often say each day at clinic. And Frances Grinstead is a recent addition from the gynecology department and her perspective on adult vaginal anomalies and helping us with some of our older adolescents, adults go through transition to adulthood is been great. Debbie Stein, the one thing that I always tell patients is I can make your baby poop, but the thing that's going to hurt them and that potentially can cause harm later in life is their kidneys. So Debbie Stein has been a great advocate for making sure that we keep that part in check together with Aaron. And I think that we have made a great team on taking care of the kidneys and bladder. We recently have Dr. Meddic who's added on and we know that the behavioral aspect, the psychological aspect, the growth of these patients really needs support in all aspects, not just physical and functionality, but part of their quality of life is how they adapt who they can talk to, how they can talk to and learn, provides a great perspective on adaptation, to care, learning about care and able to really have these kids open up. And I think that we're going to have to talk about some of their concerns. Our administrative and nursing team is phenomenal. I have to break a little bit. I think we're extremely efficient and well organized and we get many compliments from our patients that Liz and Chloe are always smiling on the other end of the phone. And we're going to have a really really grown our bowel management program. So we do our clinics on Tuesday, but they see patients all throughout the week to help manage stuiling issues, urine issues and concollege issues. Matt has been an advocate from the beginning of the psychosocial aspects of care. He is put in more than worth his time into some of these patients and we really appreciate all his work. We've had the nutrition we've had at Lauren Jalali and now Melissa Follham with us who helps from the beginning because these patients and their families don't know what to feed the kid, how to feed the kid, make sure they grow well. And I can only say so much, but Lauren and Melissa have offered some great advice to our families and hold their hands as they go through infancy to childhood. We also have to thank our supporters and collaborators through pediatric surgery department. I got a call now five years ago from Dr. Fishman asking me if I was interested in moving it all. And at that point in time, I didn't know what to say, but I'm very thankful for this court for coming here. Dr. Shambar who is extremely generous in bringing me and my family here and having to find the partners here that have been always to grow the center has been amazing. Our nursing and NPs from the surgery department from the urology side, Aaron has worked closely with Dr. Redig Boram-Bauer. Dr. Strata has been a great advocate for multidisciplinary care and with him as chief of urology, the integration and the collaboration I think is only going to get stronger. Besides Dr. Marra, we have Dr. Narek Ruflors in the GI department. Our neurosurgery, I cannot say enough about our partnership with Dr. Warf and Ashley. Any email is answered within minutes. They help our care of our kids and really move our care of their kids forward. Aaron already talked about our radiology colleagues. We work close sometimes with our plastic surgeons for some of our reconstruction. And we couldn't do any of this in the surgical reconstruction with our anesthesia collaborators and the operating room staff. And we just have to thank them for making our lives easier in the or taking care of our patients and making sure that and the other end of the operation, they look great. And finally, I want to acknowledge the SILT team who actually helped us get started. We have had great growth with the support through the marketing department, through the team there that has provided some of our administrative nursing support. And then finally, you know, Aaron and I are only part of this. I don't want to be this old when I'm and operate right here. We we want to pass this along to our successors because I think the success of this program is that it long lasts both of us. So thank you. Thank you. I think I'll jump in first just to make a comment and then open the floor questions. I want to say that there's over 250 people on screen here. And there was only a few of us who are, so I say senior enough to have watched the evolution of this field. It's hard to believe that back when Dr. Hendrin started taking care of these complex babies. Many of them were fate on omelettes. People thought like many innovators that he was going someplace where you shouldn't go and that some contrast went made to be fixed or possibly fixed. And those of us who trained under him and spent the 20 or 30 hours scrub with him on these cases saw that he was an innovator by he mostly did himself. He did partner with with radiologists and with neurosurgeons. He birthed the field of neurology in pediatrics and has built a huge legacy in both general surgery and neurology here at Boston Children's. But he mostly did it himself. He did the balleragations himself. He did the catheterizations himself and he was tired. What we've seen here, which required a bit of a transition because when when Dr. Hendrin stopped, they were a bunch of us here who would train with him and Craig little high and I sort of carried on the mantle. And I think the more important of the work and what we're seeing now is a transition to a team approach with techniques that Dr. Hendrin couldn't have possibly imagined the videos that you've shown of mainly based approaches, robotic approaches, the highly sophisticated high fidelity simulation partnerships that you've built. And we are so appreciative for both of you, Blinda and Aaron for coming together to rejuvenate and rebuild the next generation of care. You emulate interdisciplinary partnership. Most of us here have been homegrown. Aaron is homegrown as she did her final training here. But Blinda is not homegrown. And all the credit really goes to Boston for seeing the vision in attracting Dr. Dickey and her family to Cone Boston. And I know the partner with me from a general sort of perspective and passion only something that she's also an international authority on, but to really build this collaborative effort. And what all of you see when we work with them is how much people want to work with them. People stand in line to work with them. It's really emblematic of what we at Boston should be doing. Those of us who have passion for interdisciplinary care, they don't view this as a me thing. They view this as a we thing. And what we accomplished together is so much better than what any of us do individually. So I just want to compliment both of them. I'm so thrilled to have Joe Borer as a new partner in leading urology. He also has a passion for interdisciplinary collaboration, eliminate competition, do it together. Life is too short to not do it best. So I want to thank you guys for the benefit. I want to acknowledge I probably didn't say all the thank yous we needed to say on there. So I apologize if I've missed anyone there. I just saw Dr. Loffer on screen. And he is was actually a great supporter when I got here and I taught many hours of conversation with him. So thank you, Dr. Loffer. Sorry. Thank you, the are multidisciplinary approach on is exceptional on that and collaborative. And you've helped so many of our patients who we weren't able to help previously and your innovation is amazing. So thank you for all that you've done for our patients and for childrens. So I think we're near the hours. So if there's no other questions, we're happy to chat with anyone anytime. Of course, both Erin and I are open to questions after the fact. You know, we're very easy. Go on people. And we're going to go ahead off to the ORS operate together. Which is the perfect Wednesday. Thank you.
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