All right. This looks good. It looks like um we got a good number of people from our other room back in now. So I think we're gonna keep rolling um with scientific session 3 and rectal 2. So our 3 moderators for this session, um, are, uh, Doctors Belenda Dickey, um, Eduardo Perez, and Rebecca Rentia. We're really happy to have them here. Um, we can start the, um, Start the um next um presentation and we'll get some comments from the audience. All right. Good morning, or I should say good afternoon. We'll start with our first presentation. Doctor Perez, are you on? All right, um, the first presentation is from my institution, Children's Mercy Hospital in Kansas City. It's a complete laparoscopic repair of a lung channel cloaca, and we'll save that one for the end. Is that correct, Doctor Dickey? Yes, we're, we're gonna go with the second presentation, the We're trying to save some time, so we'll do the two Cloaca papers together with Marcellus. We'll start with the second paper as first paper so that you can have. Good day everyone. Welcome to my presentation. I'd like to present our study, a comparison of sexual function in male patients with al malformations between the conventional and laparoscopic approaches. The instance of sexual disorders among male AR patients is said to be higher, high as shown here. However, little is known about this issue to date. The cause might be congenital or seguera of surgery, and there's no study focusing on this issue after LARP. So, the aim of this study was to clarify the incidence of sexual problems in male AM patients after lab and to compare the incidence between lab and the sacopenial procedure. The objectives were male patients with high or intermediate type of ARM repaired at our center and aged 15 or older as of November 2020. The patients with intellectual disabilities and chromosomal disorders were excluded. Standard sarcopenia and electroplasty has been routinely performed at the hospital since its founding in 1983, but the lab was installed as a standard procedure in 2000. We retrospectively reviewed medical records and collected data like this. Questionnaires were sent in November last year, or doctors asked directly at outpatient visit to examine presence or absence of erectile dysfunction and ejaculatory disorder. Compassion between the two groups was performed. As a result, for the reasons shown here, we got a reply from 7 of the 22 patients in sarcopenia group, and 10 of 17 in that group. As you can see, patient characteristics including type of ARM, age and weight of ectoplasty, operative time, and the incidence of associated anomalies are similar between the two groups. This is a table showing sexual function. Significant difference was seen in the median age of survey. Fortunately, none of the patients complained of erectile dysfunction this time, but nearly half of the patients had ejaculation disorder. In rectal cancer surgery, damages to plexuses or nerves as shown here are said to cause possible sexual impairment. As you can see, other possible causes are listed here. But I believe what we can do now would be keeping the cost of nerves in mind during rectal dissection to avoid nerve injury and providing both parents and the patient himself with proper information before puberty. In conclusion, nearly half of the patients had ejaculation disorder after that, and the incident was similar. After the conventional cyclopedia approach, sexual problems might be an issue which pediatric surgeons have to address urgently. Thank you for your attention. Let's see if we have any questions on uh the chat, but I had a quick question is, is it discussing in the video? Isn't discussing the Uh OK, he's there. I just wanted to know how do you guys uh differentiate your, you know, how do you evalate for the ejaculation function. Uh, it, it's a direct, direct question or a questionnaire, so. So, Uh, subjective answer? Uh. I think your paper um was really nicely presented, and I think it highlights what a lot of us are thinking about is long-term outcomes after uh we do these operations as babies. So, looking at your results, would you suggest one procedure is better than another, or, um, what do you think are the pitfalls of each of them that would potentially lead to the ejacular disorders? Uh, thank you for your question. Uh, according to the, uh, fecal incontinence, uh, mm, many people have shown that, uh, there's no difference, uh, between the conventional approach and the laparoscopic approach, but according, uh, regarding the sexual function, uh, presented in this study, uh, I Um, uh, this studies, uh, couldn't show the difference between the two groups, but I Um, I think that, uh, many, many magnified views of the operative field, uh, during the laparoscopic surgery and the use of high-definition camera enables surgeon to perform meticulous meticulous procedure. So that's why I prefer laparoscopic approach to conventional approach. Great. Thank you so much. We'll now move on to the next presentation, a novel combined enteroscopy and laparoscopic approach to prevent urethral complications in the management of rectal urethral fistula by my. And this is in from the Department of Pediatric Surgery, Capital Institute of Pediatrics. Chairman, ladies and gentlemen, in the past 20 years, laparoscopic management of anorectal malformations has been challenged because of uh post-opic urethral diverticulum or injury caused by imprecise transaction of fistula, particularly upper fistula situated deep in the pelvis. We therefore design. A combined approach of enteroscopy and the laparoscopy for intraluminal incision of fistula and evaluate its efficacy. ARM patients who underwent a surgical correction using combined approach were revealed. Gastroscope was inserted into distal retina where distal colostomy stoma for Visualize fistula intraluminally. After insufflation, the fistula looks like the underside of an opened umbrella. junction between fistula and the urethral can be clearly identified. The mucosal layer was transected at the junction site using macro knife along mucosal layer. After transaction, the urethral mucosa was retracted. Rectal mucosa was completely excised under guidance of uh laparoscopy to prevent diverticulum. Muscular cough was left intact and closed by running suture to prevent urinary. Injury and leak. When patients successfully underwent a surgical correction without conversion. No significant difference in time of operation, fistula transaction, and enteroscope advancement between. High and intermediate ARM. Meantime of enteroscopic advancement in ARM with transverse colostomy was significantly longer than that of RM with proximo sigmoid colostomy. Median follow-up period was 12 months. No urethral diverticulum or injury. Occurred. Post OPMR verified the centrally placement of uh rectum with the pelvic muscle complex. VUR showed no diverticulum or recurrent fistula. In conclusion, the combined enteroscopy and The laparoscopy offers precise management of rectal ureral fistula. It effectively minimized the urethral complications, eliminating the obstacles of laparoscopy management of ARMs. Thank you. Uh, yeah, excellent job. I just had a, while we were from some of the questions, I had a couple of things. How does that like going with the scope, which I think is a pretty cool idea. But how does that make it easier? I mean, you're gonna transect the fistula at the urethra level. So, I wonder, does it make it easier or I mean, cause you're, that's the thing, that's the thing you resect the side you're resecting already. So that was my question, you know, if you don't do, you know, doing that, does it make it easier or to see it or because at the end you're gonna transect higher into the urethra side. And do you have a foley because I couldn't see a fold in the video. Do you guys have a fold in place when you're doing that, that, the suturing of the urethra? Uh, thank you for your question. Uh, uh, we put the, uh, Uh, for those young trainees do not have uh uh plenty of patience for the uh experience uh accumulation, we, we thought this is a, a good method to help them uh to identify the uh border between the urethral uh epithelium and the rectal mucosa. Uh, from, uh, uh, intra-luminal transaction, we can clearly detect the, uh, the, uh, border between and between these two parts and make a marker line. Uh, once the transaction, uh, we, we make the transaction along the submucosal layer to protect the uh ral uh uh uh system. Um. Uh, after the transaction, the, uh, urethral, uh, epithelium will automatically retract, uh, and then we, uh, peel off the, uh, rectal mucosal, uh, and leave the muscle cough, uh. Intact then we uh use the running suture to close the fisterial uh. And prevent uh urinary injury. Do you worry about thermal injury at all? I'm, how deep does that cautery go? Uh, I think that was another question in the chat as well. After the inflation, uh, the, uh, fistula will dilated, uh, like, uh, underside of the umbrella. We can see very clearly between, uh, the, the border between the, uh, urethral, uh, epithelium and the rectal, uh, mucosal. The metro sector between the daughter. I think they used the principle of PSA where we treated the fistula inside the rectum, so it's, it's an interesting concept. To combine with laparoscopy. So I'm wondering about the dissection of the, of the common wall, the, the anterior wall that we were doing with the Par between the, uh, under the laparoscope, uh. Uh, guidance, uh, from the outside we also, uh, uh, uh, dissect along the submucosal layer to, uh, provide, uh, uh, to prevent, uh, injury of the urethra. And we also, uh, combined the using the enteroscope to detect the disorder, uh, inside. Uh, this method is more accurate, uh, for, for the transaction. All right. Thank you May, May, could I, could I comment. May, could I have a comment? I, I feel. I feel, I feel using the uh bipolar is, I think, safer, because, uh, you know, polar Cory is, might have lateral thumb injury because uh dissection place is very, very sensitive place, so I think I always use very fine tip bipolar. To dissect the very distal end of the fistula near the urethra. Thank you for coming. Thank you for showing a nice technique. Yes, thank you. You, so we're gonna move on to our next presentation. This presentation is by Doctor Long Lee from Capital Institute of Pediatrics. Factors to distal bowel dilation in male children with congenital anorectal malformation. Friends, it's my great honor to give this presentation. This is our work, Risk factors for rectal dilatation in male patients with anorectal malformations. And all the authors have nothing to disclose. Rectal dilatation is commonly recognized in patients with ARMS. However, the diagnostic criteria for rectal dilatation have been rarely reported. It is still controversial whether rectal dilatation is primary or secondary to digital obstruction. The aim of this study was to specify a diagnostic reference and explore the factors of rectal dilatation in male patients with ARMS. 50 male patients with ARMS were enrolled in this study, including 25 intermediate ARMS with rectal-bulbar fistulas and 25 patients with high ARMS with rectal prostatic and rectalvasciar fistulas. On augmented pressure distal claustrographic, rectal sacral index, lens index, and the caliber index were used to evaluate rectal dilatation, fistula lens, and fistula caliber respectively. As you can see from this slide, this is how we measure these indexes. As you can see from this table, the average RSI in patients with high ARMS was higher than that with intermediate ARMS. The mean RSI in patients with without meconium per urethra was also higher than that in patients with MPU. The left picture showed an intermediate ERMS patient with a shorter and wider recobulbar fistula, and he had a less dilated rectum, but the red one showed a high ARMS patient with a longer and narrower rectal prostatic fistula, and he had a more dilated rectum. Then actually, a positive correlation was found between the LI and RSI and a negative correlation was found between the CR and RSI. These correlations were still significant after adjustment for age. Therefore, in conclusion, our study revealed that higher location of the rectal patch, longer and narrow fistula, and the history of MPU may be predictive risk factors for rectal dilatation in male patients with ARMS. And thanks for your attention. Are there any questions from this one? I just had I was a little bit confused at the beginning when you're looking at dilation, is this post-op after? The pull through, because when you look at the imaging. It's, it, it looks more like a redo. I, uh, is this, um, these dilations pulled through, are you revising them later? Uh, yes. Uh, um, yeah, our study shows the dilation of rectal dilation is actually a congenital. It's related with the high level of the rectal pose and then the diameter and the length of the fistula. So, in, uh, uh, according to our study, it's a, a congenital dilation. The first slide just shows the uh postoper put through. Uh, after PSA, uh, the patient has suffered from the severe constipation and associated with the huge dilated rectum. So you are recommending to resect more rectum like try to go proximal to try to get uh. Yeah. Because, uh, pre, uh, pre-peripheral operation, uh, rectal dilation is closely associated with postoperative constipation. So, we resected dilated rectum. In the primary service. Thank you very much. Function, what, what measures are you using to see if children have better function with this technique? Uh, uh, we use the laparoscopic. Uh, anorectal flu, uh, in our center. For the last 15 years. All right, in the benefit of time, we're gonna keep going. We have a couple of videos on Cloaca, so we'll take the discussion uh after both presentations. The first one is a complete laparoscopic repair of a long channel cloaca malformation. Uh, Doctor Wendy, as, uh, no, no, oh my gosh, I knew I wasn't gonna fumble this, but Uh, and we'll see. No disclosures. We present the case of a 13-month-old female who underwent a laparoscopic repair of her long channel cloacal malformation. She was born at 37 weeks gestational age and on examination was found to have a single perineal orifice consistent with a cloacal malformation. She then underwent an associated bacterial workup which was remarkable for a normal spinal cord and didelphic uterus. On day of life 2, she underwent diagnostic laparoscopy, colostomy creation, mucous fistula formation, and mallerian structure inspection, which demonstrates. A uterine didelphus. At 11 months of age, she underwent an exam under anesthesia, vaginoscopy, cystoscopy, and a 3DCT cloacogram. Cloacogram findings included a common channel length of 4 centimeters, a urethral length of 1.5 centimeters, a high rectal insertion into the common channel, a duplicated left renal collecting system, and a sacral ratio equal to 0.7. On pre-procedural examination, a perineal opening consistent with a known cloacal malformation was demonstrated. For the laparoscopic cloacal repair, the camera was placed in the umbilicus, and 35 millimeter ports were placed, one in the left upper quadrant and two in the right lower quadrant. On inspection of the mallerian structures, bilateral fallopian tubes and ovaries were identified, along with a uterine didelphis and vaginal candidate. The dissection was initiated to mobilize the distal rectum off of the eurogenital sinus laparoscopically. Next, laparoscopic dissection was performed of the vagina to separate it off of the eurogenital sinus. The fistula of the eurogenital sinus was closed with an endo loop. A posterior defect was noted in the urethra following vaginal mobilization. This was re-approximated with 30 viral sutures. The pile was then sharply divided just proximal to its insertion in the eurogenital sinus. The distal end was closed with a viral endo loop. The lateral peritoneal attachments were mobilized, taking care to preserve the lateral blood supply to the vagina and ureters while providing length and attention for vaginoplasty. Upon inspection of the vagina, a vaginal septum was noted. Two normal cervices were identified at the proximal portion of each canal. The septum was excised, revealing a unified vagina. A posterior sagittal anal recoplasty was performed, pulling the distal rectum through a well-defined sphincter complex. A vaginoplasty was performed utilizing an omega-shaped posterior perineal flap for reconstruction of the posterior vagina. For the urethroplasty, the cloacal channel was separated from the corporeal bodies, placed adjacent to the vagina, and matured using vicral suture to form the neourethro meatus. Postoperatively, the patient was discharged on post-op day 4 with the Foley tormain in place for 2 weeks. At 2 week follow up, the Foley was removed and the patient was able to void spontaneously. At 1 month follow up, the anus was healing well. She is scheduled to undergo an anal rectal exam under anesthesia with cystoscopy, vaginoscopy, and colostomy closure. Thank you. We're gonna go ahead and play the next video, um, as, cause it deals with the similar approaches. So it's the role of MIS and clinical reconstruction, results of a single center. Um, Doctor Baez is gonna present it from Children's Hospital, Buenos Aires. Minimally invasive surgery and its role in clock reconstruction, Garraham Children's Hospital, Buenos Aires, Argentina. The aim of this presentation is to define the role of MIS in clock reconstruction. We analyzed 32 consecutive patients since October 2001 till October 2016 and grouped them for separate analysis. They were divided in three initial groups according to the variety of approaches required for simultaneous genitorinal reconstruction in addition to the rectal laparoscopic pull-through. Group one with only perennial approach added. Combination of a Par in group 2. Requirement of a fan stick group 3 and vaginalgenesis and redo loca as special groups. Laparoscopic rectal pull-through was standardized using endoscopic assessment, sterile total body prep, cutting the peritoneum with scissors and taking advantage of CO2 dissection, followed by bipolar sealer. Avoiding monopolar coagulation until the fistula is clearly seen, sutured. And section of the proximal end and immobilization of the rectum is necessary with external or alternative MIS muscle. Stimulation and changing the position of the patient to create the channel. Bluntly, for descent of the rectum. Group 1, 43% of our patients were completely treated using a perineal approach that was progressive, keeping intact the skin bridge if possible, depending on the length of the cloacal channel, a partial urogenital mobilization of the posterior wall. Was achieved or a total eurogenital mobilization. With a complete mobilization. Of the anterior wall. was done And dissection of the vagina laparoscopically for a vaginal pull-through was also included in this group with a mean operative time of 379 minutes. Group two included only 4 patients in which PSA was done before 2007. And group 3, all the long channels where everything ended in the bladder neck and the fanicy incision was used for urethral implant, resection of dilated rectum or treatment of difficult vaginas. The 2 patients with complete vaginalgenesis were treated laparoscopically using rectum or bowel replacement, and 5 patients required a redo procedure either for matrometacarpus or a redo pull-through. 3 of them had an umbilical mitrofanov with a mean operative time of 421 minutes. We have the results together. And the operative times of the five groups concluded that 64% of our cloacas were totally reconstructed using MIS-assisted perennial approach, and MIS redoglaacco reconstruction was possible even after multiple apparatomies in a reasonable operative time. La. Thank you. That was a nice video. Um, we're gonna discuss both of these Cloaca videos sort of simultaneously as, um, procedure and, um, and techniques in the, in how we approach these. There's been a lot of comments, um, in the chat box. I don't know if people are reading them with regards to thermal energy, and, and you can see the two different approaches. Um, I think Doctor Baez uses a lot more bipolar and sharp dissection, and, and Doctor Rantea's group have used monopolar. And why you chose one versus the other. Um I, I think that bipolar energy has less, uh, less harm to the, to nerves and surrounding, uh, um. Uh, I'm sorry, and surrounding tissues around, especially when we are talking about bladder, bladder neck, and, and energy around the future of fertility. So, that's the way we train and I think it's possible, so we try to avoid monopolar, especially monopolar coagulation using monopolar cutting and bipolar sealing device. We are using now the 3 millimeter device. This is, this is a, an old series of, of patients because we were looking at the role. We are trying to see how far we can go with laparoscopy and which are the combinations of the different approaches. We know that sometimes we can do it all laparoscopic and perennial as nearly 50% of our cases. I mean, I have to say I use sharp sharp scissors. Um, there's a 3 millimeter very sharp scissors, and I do it all sharply, and then use the bipolar, um, for hemostasis afterwards. I mean, it's not really the rectal dissection that I worry about. It's really the between the bladder and the vagina. And so I think that's where a lot of the nerve damage can happen, and And I think we accept it a little bit because we know these kids are gonna be, have urinary problems. So if it does happen, it's like, oh, it was a cloaca, but I think the more that we can preserve that, I think the better it is. Mm I had a question for Wendy. Um, why, why do the septum on the first operation? Not that it's wrong, but wouldn't you wait, um, as in down the road to do divide the septum in the vagina? I'll jump in and answer that question. So, I think dividing it earlier, at least our gynecologists, um, say that it's, if it's present as a neonate and you get it really early, a lot of times then it doesn't have all the estrogen stimulation. It doesn't get quite as thick as when you're hitting puberty. So they've seen that in some children, um, when they're much older and those septums are then divided, if they have a shorter vagina, they can have prolapse and other issues because that septum was adding so much structural support. Um, if they're, if they. Missed and they're kind of right before puberty. Sometimes the gynecologist, the gynecologists will leave them, um, and then get them a little bit later, but we've seen, um, some pretty significant prolapse, um, when they're thick and the vagina is short and they're, um, not, um, um, excised early. If you can do it and it's easy and you don't harm the vaginal wall, I, I, I think it's practical just to excise it. Yeah, avoid the services, do not cause additional scarring. Vaginal wall might be thin where the septum is, so you have to be careful there, but. We always try to do that in Caracas if it is possible. I, I, I have a, uh, when we are, we are starting doing the euro gentle sinus laparoscopically and I learned from Mahmud that described that to, to To section the round ligaments is, is a good tool to bring down the vagina for uh for abdominal perineal pull-through of the vagina that you showed. And I, I, I was not doing that and I started doing it now for higher genital sinus and it's really a good maneuver. I still worry about vaginal prolapse when you always do that. So sometimes I'll leave one and take one. OK. Maybe I, I don't have enough vagina. Yeah, for, for Doctor Rothenberg, who's, who was talking about the 3 millimeter bipolar, um, is there, you know, anything that you could do with a, a, a finer instrument? Cause some of this dissection, I mean, we use needlepoint cautery, and I know that the bipolar is a little bit thicker. Is that, um, Is that a possibility? Can you guys hear me? Yeah, OK, yeah, I, you know, so I agree. I mean, there's some structures that are too thick and you can't get them in the jaws of the instrument, and I think then, you know, you have to make a decision. I'm talking more about, you know, the mobilization of the rectum or other structures down there where you're just working on the bowel wall and getting down to like the fistula. I think in those cases, there's, there's no indication to use monopolar down there anymore. I think in the complex reconstruction, because you can easily dissect down to the fistula just by using a, you know, the, the bipolar mechanism, you know, teasing the tissues off and, and working down to the fistula without doing any cutting. I think in these complex cases you guys are doing, then yeah, you're sort of stuck, um, and you may have to use monopolar cautery in those to, you know, like a hot knife or cut. I, you know, that sort of surgeon choice, but I think for the cases that most of us are doing. We can avoid all of that thermal injury by using, um, you know, the 3 millimeter, um. Uh, forceps, because you really have none. I think we are working on, so there's in a bigger patient, we now have a new device that's a 5 millimeter that has the same fine tips as the 3 millimeter, um, but it now cuts, um, it has a blade. And so it'll fit in the pelvis of some of these bigger um complex cases you guys are doing and that might work, but in some of those cases, the tissues are just too thick and then I think, you know, you guys are all very expert at getting across um those tissues and what however you choose to do it. But I think again for the majority of these anorectal malformations that most of us are doing, I think there really is no indication to use monopolar down there anymore. Hey Steve, uh, you said, uh, 5 millimeter with the blade, right? Uh, is the shaft length also short, or yeah, so we have, we have two lengths. Um, the, the shortest is, is a little, it's, it's gonna be a 30 centimeter length, so it's a bit longer, but it's, you know, we're trying to make that proceed the device that you would use in a little bit larger patient. Um, then there's also a long shafted one for, you know, for full size and adult patients, but. Um, you, there is a shorter length, um, and it's called Trinity. It's, it's, um, the new Cool seal device, but it, it, the, the key with that device, we really, it's, it's a, it's a dual action, um, you know, it's, uh, it's not a single action jaw, and it, and it, um, has a fine tip, almost as fine as the 3 millimeter, so I think it's a, it's a good dissecting device for a lot of the. So we're gonna move on to the next paper, um, which is, um, from, um, Austral Hospital laparoscopic hemihysterectomy and the didelphic unilateral cervical atresia, um, presented by Doctor Heredia. a hysterectomy in a diorphic uterus with a unilateral cervical atricia. Hurling Werner Wonderlich syndrome is a rare and underdiagnosed congenital anomaly of the urogenital tract, involving Mullerian ducts and wolfing structures. It involves uterus didelphus, obstructed amy vagina and ipsilateral renal aginesis. However, only few variants of Hovira are known. Female 11 years, menarchy 5 months ago with regular menstrual cycles, experiencing cyclical abdominal pain since menarchy appeared. General physical examination was unremarkable. Ultrasound showed a distended endometrial cavity filled with complex fluid with low level internal echoes a provisional diagnosis of hematometria was made. Uterrus didelphus was appreciated on ultrasound. Additionally, the left kidney was absent. Pelvis MRI demonstrated uterus didelphus left cervical atricia resulting in distended left endometrial cavity. The patient underwent laparoscopic left hemi hysterectomy. 3 ports were placed. Urus didelphus is appreciated. Left hemios with hematometra was clearly identified. Fine dissection has begun using a 5 millimeter device. Hemi hysterectomy is completed with a hook device. Ending with a running sitter. The sample was retrieved through the left iliac faucet tracker. Pathology was consistent on a cervical atricia. There were no intra or postoperative complications. She had an eventful postoperative stay with resolution of symptoms and resumption of normal menstruation. The patient was discharged on postoperative day one without complication with hormonal therapy. Diadelphus uterus with unilateral cervical atricia is a very rare variant of HWWs. Hemi hysterectomy is highly recommended. A laparoscopic approach, it results to be safe, feasible, and reproducible. Thank you for the opportunity to present our work. I think that was a, a very nice city. Thank you for that video. Does anyone have any questions? I, I have a concern about uh when, when you have a cervical attricia, that's such a, a hemimuller that it's difficult to resect because it's, it's thick as we could see in the video and it's next to the other cervix. So when you remove it, the, how did, how do you take Your, your criteria not to damage, but not to leave any piece of that, any mirror that will give some harm afterwards. I think that's, that's a, a nice approach when you are doing this uh procedure. How do you know when to end the dissection and the resection without leaving endometrial and without harming the other cervix? I mean, you don't need to answer, but this is something that has to be in our, in our thoughts because we don't have so many cases. So this is a spectrum, and sometimes it is very hard. So, I think it's a good, a good case to show in pediatric surgery. So just as a comment, Marcella, so we've actually done vaginoscopy from below as we're taking it off the other side. So that way you can actually visualize just as when we talked about the ARMs before doing endoscopic plus laparoscopic views, which I think, um, you know, people are using more and more nowadays, which is very helpful. Mhm. There's a couple of questions that um that we can answer before we continue. One is why hysterectomy recommended and basically this is I'm not draining, I don't know, uh. They wanna answer that and also what's the risk of uterine rupture after pregnancy for these kids. Uh, it depends. I think this case with no cervix and the other Amy Mullar and vagina, normal vagina, I think the best way to go is to remove it. It was very separate and there was no cervix. Uh, I don't know what you think, Belina, but I think this was safer for this patient, but Doctor Heredia, do you have a comment on what your decision-making was to go with that? Yes, um, ipsilateral hemis to me it's recommended. Because um the Wunderlich syndrome estimated to, to Sorry, tipsilate a hysterectomy is recommended because it's difficult to canalyze the cervical atricia surgically. And also, the canalization techniques are easier to perform, but these are associated with restenosis of the cervix and its complication, it's nearly about 40 to 60%. There you go. The, the other thing is just basically this gets a pain and it keeps growing, it's not draining, so you have to do something about it. Um, thank you very much. We're gonna go with the next, uh, video, um. Uh, wrapping the mace, laparoscopic scal fund duplication for integrade axis, uh, reflux, Wesley, uh, is gonna talk to other doctors, vendors. Uh, and, uh, let's see. Thank you for the opportunity to present our work. We have no disclosures. We present the case of a 14 year old male with a history of an anorectal malformation who presented with incontinence of his mace. His past medical history is significant for an anorectal malformation with rectal urethral fistula, solitary kidney, tethered spinal cord, clubbed feet, and obstructive sleep apnea. At presentation, he had undergone colorectal reconstruction as an infant. And had a mace placed at 5 years of age. His flush regimen consisted of 500 mL of saline with 20 mL of castile soap. While he denied any accidents or streaking, he complained of leakage of both saline and stool from the mace site in between flushes. Our institution developed a protocol for evaluating patients with anti-grade flush issues based on the timing of the problem, whether it was before, during, or after the flush. In this patient who had problems before the flush, an anorectal exam under anesthesia and a contrast study was performed. The anorectal exam found a wide open anus located appropriately within a functioning muscle complex. A contrast study through the mace was performed which revealed passage of contrast into the cecum but also refluxed through the umbilicus. After discussion with the family, he was taken to the operating room for repair. To begin, a cystoscopy was performed through the mace which revealed the channel to be wide open and unsuitable for defflux injection. Thus we proceeded with a fecal fundoplication. A 5 millimeter incision was made in the left upper quadrant as the mace was situated in the umbilicus. 5 millimeter ports were then placed in the left lower and right upper quadrants. As the cecum and terminal ileum were adherent to the lateral abdominal wall, mobilization was performed until the cecum could be wrapped around the base of the appendix without tension to create a valve mechanism, as can be seen here. The 360 degree wrap was then created using 4 oak silk sutures. Each stitch incorporated part of the cecum. The appendiceal wall. And then the cecum on the opposite side of the appendicostomy. After the first stitch was complete, a 10 French coupet catheter was passed down the mace and through the area of the wrap to ensure patency. No resistance was noted. Two further 4 oak silk sutures were placed in a similar fashion incorporating both the cecum. And the appendiceal wall to complete the wrap. Postoperatively, he was discharged on post-op day number one after pain was adequately controlled. He was able to continue his full antigrade flush upon discharge. At one year follow up, the patient is still able to perform his flushes without difficulty. He remains socially continent without accidents or streaking, and denies any further leakage from his umbilicus. Excellent video. Uh, I had, um, question regarding the first operation. Didn't they do, uh, when they did the first maze, did it just come apart, or, or why didn't they have the valve mechanism in it? I think it's institutionally dependent. I'm gonna jump in for Doctor Svetnoff. Um, it, some, some urologists and some surgeons, there's a little bit of literature out there that you don't need to do a fecal lication. And while um a lot of our colleagues do, um, you know, like they'll fix up the cecum to the fascia and they'll, they'll do it, they'll do a placation, this child did not have one. And my other question was, do you use like an optic, you use percutaneous one ear or use an optic view on that, on that lateral port? When you went in on the side. Uh, you mean like what type, how did we enter the abdomen? Yes. Um, yeah, it was just a normal 54. It wasn't an operative view. So, uh, yes, to avoid the umbilicus and optus. Um, it, you know, you can also use, you can do direct cut down on the fascia if the child has a VP shunt, etc. but Just direct Optive you All right. We'll move on to our last presentation for the session. This is the laparoscopic Approach to Inflammatory Bowel Disease in Children, a fifteen-year Experience by Doctor Igor Parabuni. This is from the Department of Pediatric Surgery, Federal Scientific and Clinical Center of Children and Adolescents, FMBA of Russia Federation, Moscow. We are pleased to present our talk to you. Nothing to disclose. Our objective was to appraise our single team extensive experience in laparoscopic surgery for complicated IBD in children. The date of 115 patients with IBD aged between 4 and 17 years was reviewed following laparoscopic procedures undertaken during the 15-year period. There were 62 patients with Crohn's disease and 53 with ulcerative colitis. In the Crohn's disease series, one-stage laparoscopic intestinal resections were carried out. Iocecal with ileocholic brought anastomosis in 42 patients. In 5 cases, the situation was complicated with persisting internal bowel fistulas, jejunal or ileal resections in 11 patients, colonic segmental resection with endostaple broad anastomosis in 2. Ultra low colonic resection with transenalute colorectal anastomosis in 4. Subtotal colectomy with straight ileectal anastomosis in 3 patients. In the ulcerative colitis series, total protocolectomy with straight ileoanal anastomosis as a one-stage procedure was performed in 7 elected cases. 2 or 3 stage procedures were carried out in 46 patients, including 17 emergency cases with bowel perforation, toxic dilatation, or massive bowel bleeding. All procedures were successfully completed with the resultant 0 conversion rate. There was no perioperative mortality. The overall postoperative morbidity was 16.5%. Two serious complications requiring further surgical procedures in the CD series were yellow colic anastomotic leak and stricture of colorectal anastomosis. The most common complication in the UC series was strichophilloanal anastomosis, treated conservatory with dilatation in all four cases. Notably small bowel obstruction after procto colectomy occurred in one case only. The laparoscopic approach to IBD in children is safe and effective, providing for good patient outcomes with minimal complications. It is there, therefore, our approach of choice rather than analogous open surgery. Thank you. Thank you for that great presentation. I had a question. Do you think that there was anything specific about the anastomosis that led to stricture? Uh, uh, about anastomosis, uh, colorectal, low colorectal anastomosis, uh, uh, in the patient with Crohn's disease, uh, to my mind it's uh it was not a surprise for us because we know that uh Crohn's patients have the opportunity to strictures in in the circular anastomosis. We tried to do it uh uh with uh. Without pull through, and it was not successful, so the second procedure was colonic pull through with colonal anastomosis. I had a question about your uh iloenos. Do you do jade pouches or any sort of pouches, or you, you guys were doing straight pouffus? Oh, in our series we do straight ileanal anastomosis for ulcerative colitis. We do vouch. We have, we have, we had the comparative examination in our in Moscow among the two clinics. In one of them perform, we perform straight anastomosis and another do pouches, and in our series we did not see any significant difference in this series, so we Nowadays we do straight anastomosis. And I see one of the pictures you, you, I saw a drain. You always leave drains on these patients or it was just a specific case? Sorry, the drain. Yes, it looked like a drain in one of the pictures. Oh yeah, we, when, uh, in all cases with the proctoolectomy, we drain the abdominal cavity for 1 or 2 days, and in all cases of oscicular resections for Crohn's disease and in all cases of procedures for Crohn's disease, we drain the abdominal cavity for 1 or 2 or 2 days. Judy, what do you think about that? No, it's not for me. Yes, uh, I don't ask. Well, I think we're gonna call it a day. It was, uh, I think we, recovered some time and it was, uh, excellent presentations. I, I hope we all learned a lot.
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