ARMs in Male Patients: Pediatric Colorectal Controversies 2014

All right, so, um, we're gonna spend the next hour on the, uh, treatment of the male, and we're really focusing here on the reconstructive aspect. And I, I think it requires a little bit of a historical, uh, introduction, um, and this is a, a famous picture from the Gross and Ladd textbook, and this is what their concept was of anorectal malformations with these. Fistuae, these H type sort of fistulae, which we all know is not really um the way that it exists. Then came the Stevens approach in which the concept of preserving the puber rectalis was paramount, because the concept was if you injured the puberectalis, the patient got, uh, was made incontinent. So then there was a perineal exploration to try to figure out where the rectum was and to pull it through. Then in 1980 was the first time that the PSARP was utilized, and this was out of frustration from Doctor Pena's perspective, having learned the Stevens technique in Boston. Um, where, uh, Justin Kelly, one of Steven's fellows, was there who was teaching all of the folks in Boston how to do it. And over the next eight years from 1972 to 1980, he got more and more frustrated with the perineal approach, and then, um, said, you know what, I'm just gonna make the incision bigger and bigger. And then eventually developed the PA, which I, in my view, really um revolutionized the care of the pelvis in many, many contexts, not just anorectal malformations, and I had the very good fortune of meeting him when I was just a medical student, um, and uh got, as he would say, bitten by the spider and have been stuck on this subject ever since. I think the next major moment of truth um was when um Doctor Jorgeson, my good friend and mentor sitting to my left, came up with this idea that maybe the rectum could be approached transabdominally in an elegant way to avoid an incision. And this was also, in my opinion, a revolutionary moment for the management of an of anorectal malformation. So that is sort of the history. I think we all agree. That the rectum. We have to be identified as to where it is ending, and it's obviously not ending in the right place. We need to ligate the distal aspect of the rectum without hurting any other structures. We have to mobilize the rectum and make it comfortably reach the perineum and put it in the center of the sphincter, and I don't think anyone would disagree with that approach. But I can assure you, many, many of these cases fall short of those principles. And what we want to try to do in the next hour is to try to figure out how to achieve that. And it really doesn't matter how you do it, you can do if you can figure out a way to do this transesophageal, we welcome that. But the goal is to disconnect the distal rectum from wherever it's connected to incorrectly, mobilize it with good blood supply, and put it in the center of the sphincters. So, let's talk a little bit about the Peace SARP. This is actually a statue I saw recently in Africa. I did not, I did not purchase it, but it sort of shows the PARP approach. Here is the positioning. And we're gonna begin, and I'm gonna talk through some of the principles with the panel, and what are some of the things to avoid trouble. So here is a posterior sagittal incision in a bulbar fistula. All right. So here we are at a key moment of truth. So, What does everyone see here? Any, uh, any comments from the panel of what, what you feel when you see that moment of this case? Yeah. It's like white fascia. So it looks midline, it looks white, it looks pretty, it looks like a rectum. But we have to know that that is in fact the rectum by a properly done distal colostogram. So here are stitches in that rectum. And then the rectum gets opened. Does anyone want to give some tricks on how they handle this part of the operation? Identifying the fistula, maybe, Don, do you have any thoughts, how, how people avoid trouble here? Uh, well, one of the things I was gonna answer is the, the stitch that goes down towards 6 o'clock is a really important suture just because you're gonna show in a few minutes when you disconnect the rectum from the fistula that the opening into the urethra can disappear. So having a traction suture on it is really important. Um, the other thing to do is you have to just open the rectum widely and just carefully look, and you can extend your incision. What would be towards 6 o'clock or anteriorly, so that you can actually try to see the opening of the fistula. You can look for what looks like a little mini dentate line. There will be the crypts surrounding the fistula opening as a clue to where it might be. I think it's really important to recognize that there's nothing wrong with opening the rectum too high. There's a lot wrong with opening the rectum too low in a Parc, because this is where this is the danger zone. You'd much rather open it up too high and then continue to open it until you find the distal aspect, which is the fistula, than accidentally be in this area and find yourself inside the urethra. All right, so here is the um stitches on the lateral wall, and here is that stitch that Don mentioned that's in the uh fistula itself. And this begins the key part of the dissection. So maybe Keith, you could comment on your feeling about this line PSAP versus this line laparoscopic. Because this is the key moment of the case. Well, um, I've done many of these both ways, so, um, I think the, the key element then is to be careful that you don't get into the urethra. And you have to look for that plane, and I usually like to start more lateral, stay right on the rectal wall. One of the advantages of laparoscopy is that you're on that rectal wall from the beginning. And as long as you don't lose sight of it, you're not going to wonder where you shouldn't. Um, and so that I think is a real benefit going from above. Going from below, I always try to stay lateral and stay on the wall and then do the medial part last because that's where the real danger is. Yeah, I agree. I think that's a general principle for all of these is the lateral wall defines the anterior. And let's talk a little bit about the lateral wall. So here is that um fascia. And one of the problems people have often is they're too wide. You really need to be close and sometimes it feels like you're too close. Jack, do you have any tricks on how to find that plane? Uh, I, I think um you, you go till you, you, you're pretty sure you're there and then you just go a little deeper. That's a good point because, because it's, it is really easy to, to be in the wrong plane and, and, uh, not deep enough on that rectal wall. Yeah, I always feel like if you can't, if it's not mobilizing, you're not in the right plane. By the way, this is true in Hirschprung's as well. You're, it doesn't feel like it's coming, you're in the wrong plane. And then I always like to say, if you see fat, you can get closer. So if you still still see some fat on the rectal wall, you can get closer to the. Um, to the rectum itself and as Doctor Jorgeson said, intimate attachment to the rectal wall is the way to avoid trouble. I think one of the reasons why there's so much trouble with this approach and there's so much trouble with the transanal the Swenson is because people were too wide. They were way too outside of the plane. You have a comment? Well, the funny part is that they think they're being safe by staying lateral, when in fact the opposite is true. You want to be right on that wall. I agree. So here's a picture that shows that that fascia has been cleaned and this is shiny, right? Raj and Payan we talk about the shiny wall, right? This is a shiny wall. We want to be closer and this little, you see this fat here? We can be closer. Here, we've done a nice job. And then the rectum gets mobilized out. All right, now let's talk about this anatomy. And think about this both perineally and laparoscopically. And I think as a surgeon, you need to understand it, the way it looks from here and the way it looks laparoscopically. So, What I see here and here, I would call levator. And then what this does is it carries on towards the skin with this line here and here, and I would call that the posterior edge of the muscle complex. And then you notice these fibers like this and like this, which dive underneath the muscle complex and carry on to here, and I would call those parasagittal fibers. Anyone, anyone disagree with that? So the center of the sphincter is from here. To here And then there's a little bit of a perineal body that needs to be repaired. All right, so here we have closed the levator, or will be closing the levator, and the continuation of the levator to the perineal skin is where this gets anchored. So let's talk about this part, the anchoring, and how this compares to the anchoring via laparoscopy. Keith, you want to make a comment about not having this part with the laparoscopy and what you've done as the trade-off to keep the patient from prolapsing? Yeah, there is a tendency to prolapse if you don't fix it, and a lot of people like to leave that out, particularly in the laparoscopic approach, which is incorrect. Uh, and so what I've done is, uh, put about 2 or 3 stitches, usually 3. Through the presacral fascia and through the wall, and it has the same effect. The other thing that I think is important is to not leave too much laxity either, because I think that's also a contributing factor, but mainly just attach that to the presacral fascia and then I use permanent sutures, not viral. To do that and um then it will, it will heal in and it does not tend to prolapse. Well, let's ask the audience who um is doing a pure laparoscopic approach for a bladder neck fistula with no perineal incision other than the only amount that you need for the anus, that would be a. B is laparoscopy for bladder neck fistula with a little bit more of a perineal incision, so you can take advantage of some of this tacking from below. So A is, is the traditional Jorgeson approach with an incision in the perineum of exactly what you need for the anoplasty and only that. B, a little bit more of a posterior sagittal incision. Plus laparoscopy, a so-called laparoscopic assisted peace circuit. OK. That's fine. Oh, that's quite a, quite a, quite a mixture. So, um, OK, for those of you who are doing. Laparoscopy with the minimalist amount of perineal incision. Who is tacking to the presacral fascia, A, who does no tacking of any kind. B. OK. So look at that. So, I, uh, Dan, do you have any comments about your, whether you've seen prolapse after this with or without tacking, or, you know, it, it, you know, when you say prolapse versus prolapse, I mean, if it's a substantial prolapse, then you've got a fair amount of redundancy of that distal rectum, and I, I would tack it. Often. Just because, uh, at least I'd love to hear Doctor Jorgensen's input on this. I, I find that we struggle a little bit more bringing the distal rectum down laparoscopically, and perhaps because we're insufflated. And so what I'm usually doing is putting some lateral stitches, about 11 centimeter cephalad to the skin, to the muscle complex in 4 quadrants to hold it in place. And I, I find that's pretty helpful. I, I, um, are you surprised, Keith, that so few people are tacking? I'm sort of surprised by that percentage. Well, I think that if they tack, they'll have less trouble with prolapse. I've had very little trouble with prolapse, although sometimes you will get a little mucosal prolapse, uh, which is easy to fix, and I think different from having the whole rectum come down. But I am surprised. Yeah, Jack, what's your approach? So I, I, I don't tack. I do a minimal perineal. Opening and I and I don't tack it, but I also don't mobilize the rectum any more than I need. I, I think that that's, you know, to, to do an extensive mobilization and then tack, it's like with fund applications, you know, taking down the entire hiatus and then fixing it. Why, why bother taking it down in the first place? So I, I only mobilize enough rectum so that I can get it down comfortably, but there's still a little bit of tension on it, and I think that's what, uh, could you give us some tricks on how you know when you have enough? Well, laparoscopically, you're, as you're taking each vessel, you then pull it down into the pelvis and you can get a sense of when you're far enough. And if you go to pull it through and you and you think it's too tight, you can always take one or two more vessels. But I think that's a, I've had very little prolapse other than the mucosal prolapse, which I don't think is prevented by attacking the retina. And I'd rather have a little mucosal prolapse than a stricture, because that can be trimmed. I, I will tell you that I use a little bit of more of a perineal incision. So that I can do a little bit of this tacking perineally. But one thing that I found is when you've, when you've dissected the rectum free, and you're trying to get it to reach to the perineum, once you've made your little perineal incision and you've grabbed the rectum. If you pull on it. Well, you can sort of see, do I have enough? And then I would just caution to desufflate the abdomen because many times before I figured out this mistake, I found that I needed more, needed more, needed more, desufflated the abdomen, and then I had way too much. So I think it's important to sort of put, and I put stitches on that distal rectum through the perineum, put a mosquito on that, so I have a little bit of tension and it doesn't feel quite right, not enough. Deflate the abdomen, still a little tight, and then you can go back in laparoscopically with that tension and take a little bit more vessels, very nice so you can see the tension lines. And just when you have enough is when you should quit. Keith, you wanted to add something? Well, I, I agree with. With what's been said about a lot of times when you pull the rectum down, it's like a rubber band and it wants to come back up and if you have a lot of if your dissection gives you a nice retraction, then I'll just maybe put one stitch in just to sort of fix it there. I don't like to open up the perineum too much because I think every little bit of muscle that I can get. To help prevent leakage is good muscle, and whenever you cut it, you weaken it, and that's always been my approach and that's the main reason I developed this operation in the first place. So here the rectum is, is tacked in position. Again, we're now PAP and uh there you now see the parasagittal fibers and then the posterior sagittal incision um gets repaired. Does everyone know what. This is What's this called? Anybody? Is your rectal fat, right? So a nice cute story that came up recently. I um. I was doing a redo rectal vaginal fistula in uh in Africa, and I saw this little piece of bit of fat. Does everyone know the affectionate term for this fat? What would Doctor Pena call this fat when it pooches into the midline, he would call it the Gonzalez hernia. That's after a resident of his who had a lot of trouble with the midline incision, and every time he violated the fascia covering this fat, the fat would pooch into the midline. And by the way, I would strongly recommend to not have things named after you as a trainee because it's usually not a good thing. So, um, and he would joke that if you didn't stay perfectly in midline, you would develop a quote, Gonzalez hernia. So, 30 years forward, and, um, Richard Wood and I are operating, and we see that fat and we use it to cover the posterior vagina. And it was great cause it mobilizes out like a, like a lipoma. So I said, well, this is really great. This is a good use of the Gonzalez hernia. So we decided to write a paper called the Gonzalez Hernia Revisited. Its use in recurrent rectal urethral, and rectal vaginal fistula, and Doctor Gonzalez himself is a co-author. So, so I contacted him and he was very happy that 30 years later, he was redeemed. It's true. It's in the literature. All right, let's talk about the anoplasty. Any tricks, Don? How do you set this up? Um, well, I put the stitches, 12 o'clock and 6 o'clock first. Um, I tie them, and then I do what you're showing right there, which is to put tension out to the sides, and I do one side at a time. I like to take, I, I like to aggressively remove the rectum, uh, so that it does retract back up in there and use sutures to pull it back down to the perineal skin, because I definitely want it to be on tension. So every single time I talk about this in Europe, there is a question, always, why are you throwing out the internal sphincter? Do you have an opinion? Well, I mean, I think the important thing is don't over dissect. I, I agree with what they're saying. I mean, I've been hearing that discussion for a long, long time, and that's been one of the big arguments about doing a PSAP like this and throwing away that very sensitive internal anal sphincter or whatever it is that you're getting rid of. So the important thing is don't over dissect so that you don't throw away too much of that distal tissue. Yeah, I, I think the, the story we all heard as children of Goldilocks and the Three Bears is very important to surgeons. If you dissect too much, it's too loose. You throw away too much, and you're more likely to be prolapsed. If you dissect too little, you're going to leave yourself with a stricture. You know, sometimes when you look at that, like laparoscopically, you can actually see the columns in that tissue. And so I wonder, why do you throw that away? Well, I can tell you from a, it's often a very practical point of view. The, in order to get it dissected free of, in this case, the posterior urethra, you end up with a little bit extra that has to be trimmed. If you don't dissect it enough, you don't have to throw away as much, but then it's tethered. So it's a judgment call. Obviously, you want to get it just right, just like uh the Goldilocks story, but um it's not hard, not easy to do. Clearly, sometimes you've mobilized it extremely well and then you have to throw it away. However, if you mobilize too little, then you're gonna get yourself a stricture. So I agree. I think it's particularly, it's easier to get it just right in a male. In a female, it's a little bit easier to mobilize too much. Um, and, uh, I'm gonna try to show some of those details today. I, I, um, definitely believe that when you don't dissect it enough, it pulls back and may be the source of a lot of um strictures in males and then disrupted perineal bodies in females. So I would rather mobilize it adequately and not deal with a stricture or a dehiscence. But throw away some of the tissue, knowing that the skeletal muscle, the other muscle tissue, not the smooth muscle, is probably the more important sphincter than the internal sphincter, which is embedded in the wall of the rectum. Both are important, but I think the external skeletal muscles probably more. It remains a real tough question. Yeah, I, I, I think a lot of this discussion is, is, is theoretical because if you have good muscles and a good sacrum and a good spine and a good repair, you're going to have a continent patient, whether you threw out a little bit of that or not. Um, so I, I, I, I, I, I think that it's, it's a technical matter but not necessarily a clinical matter. OK, let's talk about this case. Doctor Bates perhaps can make a comment about this patient had a, it's a male, had a colostomy, and here is the distal colostogram. So, from a sagittal appearance and the lateral projection, a catheter is placed through the ostomy. The, on the second image on your right, the balloon is inflated and withdrawn to plug the ostomy. A hand injection of contrast is performed to distend, uh, the distal segment. Uh, so some of the things that we are looking for, you can see on this patient, if you start posteriorly, that this patient does have some sacral dysgenesis. Um, you can see the distance from where the external BB marks the appropriate position of the anus. Um, initially, descending the colon on the left, we see no evidence of fistula, and this is where it, you must use good distention in order to see a fistula. Sometimes these fistulas are quite small and take a lot of pressure to visualize. On the second image, there's better distention. You can see somewhat rounding of the, uh, distal colonic segment, and just anteriorly, you can see a tiny, uh, fistulous tract extending up to what is beginning to fill the bladder. Right there. So, if that is the prostatic portion of the urethra, this is probably a, a rectal bulbar fistula, or very close. It could be a very low prostatic. We don't know the exact inferior extent of the bladder neck, but there is a small, tiny fistula from that point. And from a surgical standpoint, given the high position of the sacrum, you should be able to reach this from a posterior approach. OK, so, uh, let's poll the audience. A, PSAP, B, laparoscopy. While they're doing that, I, I think we, we sometimes see kids like this where, where they just cannot see the fistula this way and it's pretty easy just to put a catheter in the penis and do a VCUG to show the urethra and then just join the two of them up. Look at that, Keith. We're split straight down the middle. Um, OK, let's, uh, let's see what the panel would do. Let me guess, Keith, you would probably do laparoscopy here. Yeah, exactly. OK, Dan. Yeah, laparos Laparoscopy done, you know, it's a little bit hard to know. I'd love to know a little bit better definition as to where the bladder neck is, um, but I think the fact that there is some sacroligenesis, you could get there from behind, um, and 1510 years ago, I would have gone in perineally, but I would go in laparoscopically in this patient. And I think you can see a lot better. Yeah. I, I'd go laparoscopically. Yeah. I, I would as well. I can tell you, you can get this posterior sagitally, but it's a lot of work. Long dissection. Not so fun, laparoscopically, elegant, precise, uh, and, uh, I think in my view, probably safer. So, um, but this, I just, I put this slide here very intentionally. This is really the borderline of what's achievable PSARP-wise and what's achievable laparoscopically. Obviously, if you're a really good PSARper and not such a good laparoscopist. That's your approach. If you're an elegant laparoscopist, that's your approach. But this is the border zone. I think a lot lower than this is much easier by PSARP and certainly higher than this, you have no option other than laparoscopy. But this is the border. And one of the things that someone pointed out is the anomaly of the sacrum, which clearly makes PSARP a little easier here. A normal sacrum, this would be a very difficult PARP. A foreshortened sacrum, you have a lot more room. But this was put there very intentionally. So here is a, uh, you want a question, Dan? I, I was interested in what Doctor Jorgensen would think about the, how much colon you've got to pull down that rectum. And I think that it would be tight and it's not unusual to actually have to take down the distal side. One of the problems that I've seen is that when people construct their colostomies and they're planning to do a laparoscopic approach, they think, well, I've got to get that way out lateral because if I don't, I won't be able to see into the pelvis. But since you're approaching it, usually from the right side. It's, it's better actually to have it more medial because that will help you get this down and you have no trouble with vision anyway. I, I think it looks like there's probably enough length, but I'd want to see the AP view to see really if there's enough length, which, which maybe um you can comment uh about Greg, the, um, how important it is to show that first. The surgeon's perspective, just to get your technique, pretend like everyone here is sitting next to their radiologist. What would you tell them to, uh, to make sure to do when you do a distal cholotrogram? I think you have to do both the lateral. I started in the lateral projection. Our current protocol here with. The information that you're looking for based on the cholostrogram and what the neurologists are looking for in a VCUG, we do a combined cholostrogram with VCUG at the setting. I think it's very difficult to do a VCG through the fistula. To to get adequate amount of information from that. So we'll do, I tend to do the cholostrogram first. I can take the contrast out of the distal colon at the time with the catheter in place and then turn around right and do the BCUG. So that's our, that's our standard protocol. We do both at the same setting. Um, in terms of getting not only just the lateral view, I get oblique NAP views in full distension always, and we do exact measurements. You can see the ruler, uh, on the patient, and we measure the exact length of the colon, uh, and report that to the surgeons primarily as well. All right, here is a PSA image. What does everybody see? Gonzal hernia. I see a Gonzalez hernia. Very good. This is Gonzalez Hernia. What is this? It is midline. It is white. It's very pretty. It's viscera. I always tell people that that's the viscera. It's a visceral structure. You don't know what it is. This is a thing. Doctor Meneci, you and I bonded over this case. What is this? That is the bladder, everybody. That is the bladder, and I can tell you, it looks a lot like a rectum, doesn't it? It looks very pretty. You want to mobilize it. This is the bladder, and the only reason why we knew for sure that this was the bladder is because we had a very nice distal cholostogram. And you, that bladder, well, here's the coccyx, right? So this thing is in the bulbar zone of rectum, but we knew that this was a high prostatic fistula, and that is why it's so vital to get a proper study, because there is, as soon as we saw this, we said there's no way that's the rectum because the contrast study didn't show it to be so low. So look at that. This is the bladder. And that little thing underneath the coccyx is the rectum. So this is another border zone case. This could have been laparoscopic. This could have been peace art. But here is rectum. This is bladder. This is really a dangerous, uh, dangerous view if you don't get that right. 11 thing that you could do if you're not sure is just bring a flexible um. Neonatal scope, put it through your mucous fistula and pass it down, and if you'll see the light, I mean, exactly where you're going, which helps. That's a good idea. All right. So let's talk a little bit about this. So, Doctor Bates, your assessment? Well, actually, before you speak, who says A, bladder neck fistula, B, prostatic fistula? They're, they're the different patients but same anomaly. A, bladder neck, B, prostatic. All right, so everyone pretty much agrees it's bladder neck. Do you agree? I agree. Yeah, I think, and I think we all have to commit to always saying whether it's bladder neck, prosthetic, or bulbar and never using the term rectal urethral fistula. It's just not specific enough. All right, so, um, uh, laparoscopy or PSARP. Laparoscopy A, PSAP B. All right. So from a technical point of view, and I'd like Keith's comments on this, from a separation of the fistula perspective. This is actually easier than a prosthetic. However, for the gaining length perspective, this is harder. So your, your thoughts on that and your tricks. Well, usually for a uh. In a fistula of the bladder neck, it goes in usually at right angles. And so it's pretty easy to define. It often narrows down quite a bit. So again, it's fairly easy to define. So in my view, a laparoscopic approach is really quite easy. If you can't tell where it goes in and you're worried because you're afraid you might get into the bladder neck, you can always open the colon and then look for the fistula inside. It's it's an easy trick. If you've cleaned out that distal bit of colon, you don't have to worry about spillage. And even so, with the laparoscopic approach, you've got pressure in the abdomen, so it usually leaks very little. And Jack, how do you decide how low to go? What is your criteria of how distal on the rectum before you, uh, lop, lop it off? Well, I, I like to see it narrowed down because it, it almost always narrows down. And uh once it's narrowed down significantly, that's where I usually take it. Yeah, so I, I do it the way Keith showed me and it has to be, you have to put the 3 millimeter Maryland across, and if there's no extra tissue, that's low enough. Um, everyone agree with that, or do you have a different, I just, I just think it's, it's usually not that difficult to know where you are with these bladder, neck, and prosthetic fistulas. People who do the bulbar fistulas laparoscopically, I think that's where you can get into more trouble and it's much more difficult. Yeah, I, I, I would agree. And then, um, Keith, could you just describe your trick of ligation of the fistula? Well, I always use a loop. I initially clipped these. I had one fistula from that, and I was told by my urology colleagues that metal clips tend to erode into the urethra anyway. So after that one experience, I've always taken a loop, um, grabbed it with a clamp, grabbed the distal fistula with a clamp, and then just passed it over the loop and then slid it right up over. Uh, the Maryland and tightened it and you get a very nice, um, closure right on the wall. It's a very nice trick. So you preload the Maryland through an endo loop, then you cut, then you put the endo loop over the Maryland, um, and then you have total control of the situation. Just, um, quick question, you know, or, or just a comment about, I, I think. You can come and come across a little more cephalad than that, because if you go too far down. You know, that gets away from you and it starts slipping upward, and you can drop your endo loop much more distal, and then if you have some extra fistula tissue, just cut it away later. But, but you can really burn bridges by going way, way so distal where you come across, and, and that makes it harder. Yeah, one thing I found is that the loop should trail the, the stick. The stick is what you put distally. A lot of people try to make the loop go distal, and it's much harder to control if you take the stick and put it distally and the loop is trailing behind, then you get a very nice approximation. So maybe we could ask, uh, um, Greg, how do you decide what's a prostatic and what's a bladder neck based on the contrast study. What, what have I labeled these slides correctly? You have labeled them correctly, I would believe. Um, Lateral one, looking at the angle of the urethra, if you want to use that margin as a relative cutoff, I think, you know, the, the diagnosis is often made on what tissue is present, and I think sometimes without adequate distention, you can have difficulty determining, is it truly a prostatic or bulbar, but we, I we tend to use the angle of the urethra and a well distended urethra as the marker for bulbar versus more proximal as uh prostatic. Bladder neck, clearly, with a good distention up in the bladder neck, not involving the posterior urethra. We have um joining us some of our urology partners. Anyone gonna give us some thoughts on Maybe Doctor Curry can tell us what, how do you define the different parts of the urethra? We'll, we'll get you a, a, a microphone because we have, uh, folks who want to hear you from the international. Yeah, um, good morning everybody. Um, I always wondered why you don't take advantage of your urology colleagues and, and have them do a cystoscopy for you and tell you exactly where the fistula is and, and if you want, uh, a little ureteric catheter placed in it, mark it for you, and, and, uh, make life a lot easier or do the cystoscopy yourself if you feel comfortable doing it. We do, we love having urology join us, but I can tell you, um, I remember about 10 years ago. Doctor Pena and I decided to cystoscope every single primary case because we were hoping to find the holy grail. The holy grail would be every fistula would be defined cystoscopically, you would never need to do a distal cholostogram. Well, guess what? About 7 out of 10 patients, you saw no fistula, cystoscopically, at least in that little cohort. I think the bladder necks are quite obvious usually. I don't know what, if you guys have this opinion also, but often the bulbars, you did not see the fistula cystoscopically. And I don't think it was a lack of a good cystoscopy. I just think it was a tiny, tiny hole. Um, I would have loved that. That was going to be the holy grail. We were gonna never do a colostomy in an ARM, and then of course that didn't work. So, so this was a scoping done by a urologist or a surgeon. And that may be a good point, but I found the same thing. I thought, I'll find this. Ahead of time I know exactly where it is great and found that at least half the time I couldn't find it. Now it may be that if we had an expert cystoscopist, it would have been a different story. Yeah, so I would suggest you repeat that study again, get the urologist to do the cysto for you, and I think you'll find it at least 9 times out of 10. We'll do it. We have some some super partners here that I'll probably be happy to do that. Um, from a radiologic point of view, one of the things I like to tell the fellows is what's bladder neck, what's prostatic, what's bulbar, is I imagine the urethra is like a, like a C or like an elbow. And if, if the fistula comes in at the elbow or below, I call that bulbar. If it's above the elbow, I call that prostatic. And then if it's at the bladder neck, I call that bladder neck. And of course, Mother Nature loves to put them right in the middle of those, but essentially the two items that I want to know are where exactly is the fistula, and then how low is the rectum, meaning this rectum is pretty bulbous here. And might be much, much nicer to reach posterior sagitally, whereas this rectum is very coned down and there's no way you're going to see that posterior sagitally. I think that's an important characteristic, and I think I have a picture of that. Here is a bulbar fistula that's super low. And one of the things that can happen here is the surgeon can go in. Without a proper study, grab the rectum and do a beautiful anoplasty and ignore the fact that there's a fistula. And we on this panel, I've all seen patients who have been, who have peed. Out their anus because no one ever dealt with the fistula and I would call that a persistent fistula, meaning the fistula was never managed as opposed to an acquired fistula that you uh that you created, for example, that is a fistula that was never touched and a very low bulbar rectum like this is one that you can do that for. All right, here we go. So, a PAP. Let's do the left panel first. The left panel first. PSAP A laparoscopy B. Ignore the right panel for a second. That's Yeah Would it go? OK, what do people think? Split. All right, now let's look at the right panel. A PSAP A laparoscopy B. OK. Look at that, isn't that funny? So, um, I can tell you the, these are, uh, the case on the left I had on a Monday and the case on the right I had on a Tuesday. And I said, oh my gosh, this is really cool because the fistulas are essentially the same. But the rectums are very different. Would everyone agree with that? The fistulas are basically at the elbow in both cases, but these are completely different rectums. So, uh, Keith, laparoscopy on the left. Yes, yes, and yes. You know, whenever you see a fistula like that, where it narrows down that much, it's a great laparoscopic case. The, the left side is beautiful for laparoscopy, no question. The right side, I might be inclined to do PSAP because this rectum is a little bit bulbous. There's nothing wrong with laparoscopy here, but I would probably go after this because it's right there. Dan, left side laparoscopy. I, I'd end up doing absolutely right side it's a flip of a coin. How it depends how you feel that day. You got it. OK. Depends what the resident wants to do. Uh, yeah, a resident advocate at all times, and they always want to do laparoscopy. Don, I do laparoscopy on the left and a P serp on the right. All right, great. All right, so, um, then the second holy grail I thought was laparoscope every patient because then you could tell where the fistula was. And this is what it looks like, right? So this could be a bulbar, prostatic, or a bladder neck, because basically you need to do a little bit of a, uh, peritoneal dissection to figure it out. So that was not the holy grail either. Um, any opinions about this? Well, you have to do more than a little bit of dissection, I would say, to determine that. But again, I would just mention the fact that if you are doing that dissection and you just don't know where it is and you're starting to feel like, gee, I'm getting into trouble here, you can always open up the rectum and you can find that fistula always from inside. Yamataka in Japan does it every time and he measures how much fistula he's willing to leave and he leaves 3 millimeters. So I mean he does it every time, but I don't do it every time. But if you don't know where you are and you'd like to know, it's a quick and easy trick. All right, so let's talk about the ligation of the fistula. So we talked about the laparoscopic way. This is a bladder neck fistula. And then the laparotomy way, and they're comparable, and this is how they, this is how they look in these two circumstances. And then uh what this shows is the, uh, is the way of ligating that we already talked about. Preload the, uh, the Maryland, ligate over the Maryland once you've cut. All right, now let's talk about how you get a very difficult rectum to reach. This is very tricky sometimes. Tricks, Jack. Well, I think before you start, you have to get a sense of how difficult it's going to be. Most of them, just by taking one vessel at a time right on the rectum, you can get it down where you want it to go, and the rectum has an excellent, uh, blood supply intramural, so you can divide a lot of those, those, uh, vessels. The ones that are really high, you sometimes you have to go back and take a, you know, uh, take a vessel higher up and leave the marginal artery, um, but that becomes tricky if your colostomy has, has divided that marginal artery. So you have to be very careful to make sure that you've got a good marginal. Does everyone understand that that's uh probably one of the most important points to walk out of here with is the difference in mobilizing the rectum of ARM versus Hirschrunk's. So in Hirschprung's, you can take the IMA with a lot of confidence because you have the left colic and the arcade down the sigmoid, and it will just reach. In ARM there has probably been a division of some of that blood supply during the creation of the colostomy. So you cannot take the IMA. If you take the IMA, the rectum will most certainly reach, but it will have no blood supply. So you are obligated to depend on the IMA. And then the intramural blood supply depicted by these pictures. And therefore you need to dissect just along the rectal wall, which is what Keith was talking about earlier, because you know you have an IMA branching and an intramural blood supply, and the rectum is very cool in that way. There's no obvious mesentery, but it has its blood supply in the wall. And then I just put this on on rare occasion you need the rectum a little bit more, and here's a nice trick. Sometimes these rectums are a little bit bulbous, and you can do a Heineke Mkulitz plasty. You can cut horizontally and suture vertically and solve two problems at once, taking care of the dilation and gaining about 2 or 3 additional centimeters. So here's what that looks like. This is open. Here's the mucous fistula taken down. Here's the rectum that we want to reach. And this is the bladder retracted, and there is, uh, how do you figure out if you have enough rectum, meaning if you can do your pull through. Do you have some landmarks, Don, that you use in the pelvis that say this rectum will reach if I pass it through? Well, I think it's a hard case. I mean, I think that one of the, the ways you definitively make that decision is to make your, do your anal dilatation. However, you're, if you're going to make it, do a mini PsAP or you're going to pass, um, a step trochar down through the location of the anus, and I put traction sutures on the distal rectum and just keep pulling it down until I feel like I have enough length. I, I think it's just to take it as you come. Um, one of the things I was going to talk about is I think you very commonly have to take down the mucous fistula. Yeah. At the same time. You have to be prepared to do that. And I have on occasion actually taken down the colostomy and so that I don't have to go back later and try and take down the colostomy and do what's the equivalent of an old fashioned open low anterior resection anastomosis. So, I would take the colostomy down at the time of this surgery, And then do a backup ileostomy. But to answer your question, it's not easy, and I think you have to, um, look at all your blood vessels, and I use bulldogs to put the ones to try to figure out which vessels I can save without having the rectum die before I divide anything. You, you said many pearls in that little discussion. First of all, the properly placed colostomy. At newborn is going to prevent a lot of the colostomy takedown requirements down the road, so it's can't be underemphasized how you have to be as proximal in the sigmoid as possible. And um also if you're, if you have the situation where you have to take down the mucous fistula. That may gain you some length, but then you're going to give yourself a very annoying colostomy closure. So then you can do a colocolonic anastomosis and then decide whether you're going to divert more proximally or not. But I agree with that. I hate doing a Hartmann's closure behind the bladder. One of the rules of thumb I use is to try to get this rectum to see if it's going to reach, as I want it 2 finger breadths or 4 centimeters below the pubic bone. And if I put a mark on the perineal skin right at the top of the penis, that a blue mark, which is basically two finger breadths below the pubic bone, over the pubic bone, I know that if I pulled it through the pelvis, it will reach the anus. Sort of a nice trick. So this is what we were talking about here. You're going to dissect right along the rectal wall, but preserve the IMA branch because then these little blood vessels in the wall are alive. And that's what that looks like. Look how we skeletonized this rectum, but we preserved the IMA branch and all these vessels here are alive. And here is a point about 2 finger breadths below the pubic bone, so this rectum will reach. All right, so I just wanted to show you this picture. This is a minimal PSAP incision that I think has some advantage that we've talked about, and there's, you know, two ways to do this. You can make a much less of an incision or this relatively minimal incision, which allows you to get into the pelvis and then do the tacking, but I think we talked about that already. And then, uh, pull through the rectum. You don't have to put the patient back in prone, uh, position. You can do it like that. All right, one cute clinical point to end this is a patient I think we showed before. What does everyone think about this malformation? This is a newborn. Put a hagar into this anus, it doesn't go anywhere. So what would you call this? Rectal atresia now that you're experts, rectal atresia, right? So, and there's a sacral X-ray. Bates, you have an opinion about the sacrum severely dysplastic and may actually be a hemi sacrum. There's a component on the left. So everyone see? So there, there was presacral mass in that space. Another example of that splits kind of a split sacrum presacral mass. By the way, not all hemisacrums have a presacral mass, and not all presacral masses have a hemisacrum. And most pure reno triads are not all three. So thanks a lot. Makes it hard on us, but, and um how about this contrast study? Obviously anteriorly displaced rectum from the sacrum, so there's a large presacral massively. Do you see this? This should bother your eye. Something's here. That's a presacral mass. And let me just show you this. This is a cute approach to saving this dentate line, and we have a nice video of this, which we're hopefully going to be able to show you today. But rather than mobilizing the distal rectum here, you can simply split it. So the 360 degree anus now becomes 180 degrees and open. Like this. And then you can mobilize the distal rectum. And then you can suture it. To the dentate line. And here is another example of that. Here is the rectum. This is a stenosis case, and I think I have a picture. So look, so this is, here is a, um, you want somehow convert this circle. You need to uh anastomos this mobilized circle to a hemicircle. So the way I like to do that is if this is the, this point used to be here. Right, and we've split it. So now this is a, a clock unfolded like this. And here is the circle, so if you just match up. 12:00 6 o'clock to 6 o'clock. 3 o'clock, 9 o'clock, 12 o'clock. Does this make sense? So that your circle is anastomos to your hemicircle and you have successfully then preserved the dentate line without any dissection or removal of the dentate line. This is in the rare circumstance of erectile atresia or stenosis.