Presenter: Brian P Fallon, MD
bfallon@med.umich.edu
CLOACA REPAIR WITH IMAGE-GUIDED AND COMBINED ENDOSCOPIC AND LAPAROSCOPIC (CELS) ANORECTOPLASTY WITH DELAYED UROGENITAL RECONSTRUCTION
Brian P Fallon, MD1; Marcus D Jarboe, MD1; Bryan S Sack, MD2; Elisabeth H Quint, MD3; Matthew W Ralls, MD1; 1Section of Pediatric Surgery, Department of Surgery, University of Michigan; 2Department of Urology, University of Michigan; 3Department of Obstetrics and Gynecology, University of Michigan
Traditionally, cloaca is repaired through an open posterior sagittal anorecto-vagino-urethroplasty (PSARVUP) and abdominal mobilization. Despite years of developing this technique, functional outcomes remain poor, including obstructed menstruation in 38% of patients and amenorrhea in 25%. This video presents an alternative operative strategy with delayed urogenital reconstruction. This muscle-sparing approach begins with real-time MRI-guided needle placement through the anal sphincter complex and levator ani, followed by combined endoscopic and laparoscopic (CELS) rectal mobilization, and finally anorectal pull-through. The patient in this video was born with persistent cloaca with no cervical os identified, no hydrocolpos, and normal bladder capacity. The patient’s family was counseled by Pediatric Urology, Adolescent Gynecology, and Pediatric Surgery. They elected to delay urogenital reconstruction and proceed with the above-described anorectoplasty. With appropriate patient selection, this technique addresses fecal diversion only with urogenital reconstruction delayed to an age where the patient can actively participate in shared decision making.
Intended audience: Healthcare professionals and clinicians.
This is a case of a 5 month old baby girl with cloaca. Shown here is a representative slice of the MR cloacogram. Important anatomical landmarks include a 2.7 centimeter common channel length and a 1.4 centimeter urethral length. Note the levator ani as well as the sphincter muscle complex and the nonlinear path into the pelvis. Here the cystoscope shows the common channel and the takeoff of the urethra. With the advancement of the scope, we found multiple fibrous bands and pits. No definitive cervical structures were identified. We were able to pass a wire and then a scope only through this opening. This was the rectal fistula. On laparoscopy, bilateral ovaries were identified. Both were associated with diminutive adnexal structures above the pelvic brim. Because of these findings, along with a normal bladder capacity without evidence of vesicoureteral reflux, an anorectoplasty alone was discussed and agreed upon by the multidisciplinary group. The rectum is retracted from the pelvis and the lateral attachments are dissected to expose the rectal wall. The dissection is continued with hook cautery with significant tension and counter tension to enable the surgeon to remain within the avascular plane. Care must be taken to stay close to the rectal wall to avoid damage to the surrounding pelvic structures. As the circumferential mobilization continues, the inset shows an example of real-time MRI needle placement. The ability to see the needle in real time allows for adjustments to stay centered within the muscle complex. The difficult dissection between the rectal wall and the low pelvic structures is simplified with this technique. With persistence, the fistula track cones down, and the last few fibers can be taken with the hook. When completed, the pelvic floor muscles are easily visualized. Note the needle traversing the floor just posterior to the fistula. At this point, a cystoscope is introduced into the common channel and rectal fistula to ensure transsection at the appropriate level. The fistula is taken with a 5 millimeter stapler, and then at the level of the insertion. With a PDS and a loop. The staples are removed to complete the abdominal portion of the case.
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