Cloacal Exstrophy: A Modification of the Newborn Operation - Leaving the Cecal Plate Untouched

Cloacal atrophy is the most complex of all the anatomic problems faced by the pediatric reconstructive surgeon. Here you see a typical newborn with cloacal atrophy. The yellow outlines the phallocele, the light blue, the hemi bladders, and the dark blue, the cecal plate. Often the distal ileum and appendix are intersuscepted. The traditional approach to the newborn operation is to separate the fecal plate from within the two hemibladders, tubularize it, and add it to the fecal stream. The rationale for this was to maximize the amount of colon the patient had and to avoid resorption of urine by bowel mucosa. However, over time it became clear that the tubularized cecum was problematic as it led to stasis and bacterial overgrowth. In addition, urinary absorption by bowel did not lead to the clinical concern of acidosis that had been expected. In the traditional newborn operation here you see the fecal plate has been mobilized, dein suscepted, and is about to be tubularized. The end of the hindgut will then become the end colostomy. The two bladder halves are then closed to each other and reconnected to the phalocele. Here in two different cases. In the photo on the right, the ureter orifices are catheterized. We propose a new way to do the newborn operation, leaving the fecal plate untouched and performing an ileal to hindgut anastomosis. There are several advantages to this approach. It avoids the technically challenging separation of the fecal plate from between the two hemibladders. It allows for an auto augmentation of the bladder. The ileum to hindgut connection is a 1 to 1 size differential. It avoids the tubularized cecum, which down the road leads to problems related to dysmotility. In this video, we present a newborn with cloacal atrophy in whom we left the fecal plate untouched. The patient's phalocele is relatively small. The two hemi bladders are seen, and the cecum is between them with the distal ileum, and appendix into septate. The operation begins by incising at the lower edge of the phalocele between it and the fecal plate and the hemi bladders. Through this transverse incision, the abdomen is entered. The cecum is then deintersuscepted. We are now looking for the hind gut, and we find it. It's about 12 centimeters, a good length. It ends blindly as a colonic atresia. Essentially this is just the right colon. The hindgut is mobilized, preserving its blood supply. Here you see the distal ileum entering the cecum. We are now cutting across the distal ileum and over sewing it on the cecal side. The cecum and appendix are untouched. Here is the distal ileum tagged with a suture. You see the distal ileum on the fecal side, which has now been oversewn. Now we cut across the proximal hindgut next to the cecum. And we close the hindgut on the fecal side. We line up the distal ileum with the proximal hindgut. Note the smaller hindgut lumen. We needed to perform a Cheadle maneuver on the hindgut to set up a better aligned ileum to hindgut anastomosis. And now we perform that anastomosis. The anastomosis is complete. And now we grab the distal hindgut to set up for the end colostomy. And now we perform in. Here you see us closing the bladder. We have placed a foley in the vesicostomy and now tacked the colostomy to the fascia. We excise the phalocele to create an umbilicus.