OK. So here we go. Here's a baby. We talked a bit, a little bit about this diagnosis. Uthra, vagina, pole. Sphincter diagnosis? OK. A, perineal fistula, B, vestibular fistula. A perineal fistula, B, vestibular fistula. Normal urethra, normal vagina. Whole. Great. Everyone agree? OK. This is what Eva was talking about before. This is a really nice technique is to hold these labia up and out. You can see urethra, vagina. Who. A perineal fistula, B vestibular fistula. Experts now. I'm sure they're going to get this right. All right, Vicky? OK. All right, same idea, same idea. OK, how about this one? Paula, you have an opinion? right at the ochette. OK, so that's urethra and vagina, and the hole is as Paula is describing it, the fourchette. Yeah, so, so is this, I guess this is perineal at the forchette. Yes, OK, vestibular at the is when Mother Nature is up there chuckling at us when we try to make these distinctions. All right, a little bit about the technique. This is in in prone position stitches around the fistula. Mobilization Now let's talk about this plane here. How do you know you've mobilized enough, Don? This is a, this is a perineal Forchet fistula prone position. How do you know enough is enough? Well, I don't care if I get it completely off the vagina. OK? That's not my goal. My goal is just to mobilize it enough to get it to reach the perineal skin with a little bit of tension. So my answer is when I pull down on it and it reaches the perineal skin with a little bit of tension, I quit. Ivo, you agree? Not completely. I, but I, I can imagine, but um. I'd like to have it completely separated from the vagina because you'll find there's a. It's always very attached attached to it. It's like like the common wall. If you finally get it loose, you can place the tension free, and once I have the feeling, but it's a feeling that if you don't do that, you may get more retraction and wound, wound problems if you don't really get it free from the vagina. So we've had the discussion before as well. I think a lot of. Uh, retracted, uh, anoplasties are Related to not getting it loose enough and if you sometimes do a redo, you find that this plane, this plane which separates it hasn't been touched before. So, my feeling is you have to get enough to separate it. The downside is a little bit that you lose more. We did discuss about you lose more of your, your internal sphincter or your rudimentary internal sphincter tissue or you will lose some of it. But I, I, my feeling is, is more not to get any wound problems and. So I, I tend to go. Until it's completely loose from the vagina. Yeah, me too. Michael. Uh, I, I agree, uh, with, uh, a little bit more mobilization, um, so that, uh, you can't bring it, bring the, uh, rectum down without tension, uh. The other thing is, even though it seems like such a straightforward case and, and it can be, um, you need to, to be careful because if you are slightly, um, too far away from the rectal wall, you will end up in the vagina because even though there's a separate plane there, um, you know, uh, compared to the, the stibulars where it's more of a common wall. It's really, you could, you could, uh, get into the posterior vagina easily. OK, so now that you find that completely clear what to do, your current practice is A, mobilize just enough so it reaches, or B, ensure a complete separation of rectum and vagina. It's like. A mobilize just enough so it reaches B, ensure a complete separation of rectum and vagina, knowing you're going to have to throw out a little bit. All right, so we will see this afternoon that these little details in the case. My personal feeling is, and I, I acknowledge I'm very biased on this topic, because we do so many redos of females. And in every single redo of a female, I find that perineal, I'm sorry, that areolar tissue that had never been dissected by the original surgeon. We know it. We say, see, no one, no one was ever here. And so my conclusion from that, and I may be wrong, my conclusion from that is the redo, uh, that the reason for the redo was the perineal body disrupted, and the patient's left with no perineal body. That somehow the anterior rectal wall was not free enough and it pulled back. So that's why I'm very biased to try to get to that areolar tissue that shows that the two structures are separated. I'm sure what Don is saying is right, and you can do that and get a beautiful anoplasty, but if you have any tension on that anterior wall, you can disrupt your, your perineal body. You want to comment? I'm, I'm just listening to what everybody is saying. I don't recall having those perineal complications, so maybe I'm mobilizing it more than what I'm describing. But my also my other comment was going to be. How many of those redos that you've done were done sort of in a newborn period without a backup colostomy, without a colostomy, because a lot of the newborn female vestibular fistulas that I've had to redo were done without a colostomy. Yeah, I think that's an important point, but many, many have been done with colostomy. Every, all, every, all conditions perfect, but the surgeon did not dissect the anterior wall to the point where you get to that areolar plane. And then again on the other side, every single female redo, we find that plane that had never been dissected. So I believe that that is an important technical point. Um, all right, and the tacking once again, and there's the anoplasty. OK. All right, so this picture is um An interesting one. Jonathan, I think you alluded to this before, urethra and vagina are normal here. So, what is this talked previously about an entity called the common perineal groove, and this seems to be in association with an anorectal malformation per se, i.e., it looks like there's a stenosis. So looking at the two things separately, I wouldn't, I haven't found patients becoming symptomatic from a common pineal groove. But let's, let's ask, let's ask everyone. I will tell you there's a normal urethra and normal vagina here. That hole is in the center of the sphincter, and it accepts a number 1112, Hagar easily. In a neonate, is that like. Huh? In a neonate. Neonate. Neonate. OK. So, A, Surgery. B, observation only. Do you I'm. After the first year relationship. Play. OK, would any of the 12.7% of you want to comment on surgery? Ah Dr. Teitelbaum. By the way, just so you know, uh, the fellows are doing very well with their answers. There are 2 of you that will not be able to participate in the afternoon session. We have booked your, uh, we have booked your flights. Connie will let you know the new arrangements. OK. So I, I throw this out to the panel about this mucus and if people observed, if you don't. A few years later, do you find any problems if this is left alone? So again, normal urethra, normal vagina, right, right. Anus in the well, in the proper location and good size. And there's this thing, this mucosal lined channel between vagina and anus called a perineal groove. Jonathan, the only problem that I've seen is in an older child that was referred because it caused confusion. In the GPs' minds about whether or not this was a standard fissure in a. Um, so once it's got a name and a label, um, for me, um, I've always been treating them just based on symptoms. My colleague Ian Sugarman has had a patient who was troubled because it produced a fair amount of fluid, and the procedure that he did was just to excise the mucosa and just close it, and it was very straightforward. Yeah, I think the vast majority of them, if they're observed, will become normal skin over time. Yeah. Yeah. And the ones that don't, it's a very simple fix to just unroof the mucosa and suture it up if it's causing mucus production. But it's, it's an interesting entity, and it's often associated with a perineal fistula. Um. So, then if you're going to fix the anus for the perineal fistula, you might as well just unroof the, or get rid of the mucosa. question. Dr. Downey, how are you? Thanks for coming. Isn't this just a picture of embryology? I mean, if you think about the, the analogous structures in the male, this is just an opened up. If you will, form first fistula that goes up to the scrotum, like you would. I mean, that's what it's, I've always thought of it conceptually as being, that's clearly mucosa. So you just leave it alone and it, it'd be fine. You just leave it alone. Well, I also make a point of just going through the clinical aspects of those just because I think it is part of the spectrum. I wouldn't submit them to a lot of radiation, but I'd listen to the heart, etc. OK. A perineal fistula, B, vestibular fistula. It's a test to understand you. It's a test. A perineal fistula, B, vestibular fistula. Right. And then the mobilization of the, and we'll talk about this in the OR so we don't have to spend a lot of time, uh, today, but dissecting the posterior rectal wall and then the lateral edges before going anterior. And here's a nice separation of rectum from vagina with no holes in the vagina. So hopefully we can achieve that today, but If there is a hole today, it's for instructive purposes, of course. If you have to make a hole, which would you choose, vagina or rectum? EO. Don't ask the gynecologist, but the opening in the vagina. Vagina. Yeah, so it's it, and why is that? What is the technical reason for your much rather making a hole on the vaginal side than on the rectal side? Well, it heals, it heals very well, and you don't really get any much complications. And I would also add that the rectal blood supply is intramural. So the last thing you want to do is injure, injure the rectal wall because then you're hurting its blood supply. Any tricks, uh, Michael, for making this a beautiful uninjured posterior vaginal plane? Well, I think, uh, you coming and starting laterally is really the key, I think, um, and you really wanted to find that lateral plane before you even attempt to start separating, uh, or creating two structures out of one common wall there anteriorly. Um, the lateral defines the anterior. I think that's a very important guiding principle. And then here's the back to this discussion. Is this too much dissection or is this the appropriate amount of dissection? So we sort of talked about this already. I personally like to go to the areolar plane that exists here, knowing that I'm, I'm going to have to throw away about this much rectum, but I'm willing to accept that because these patients are going to be continent on the grounds of having normal. Skeletal muscle. Mark, so could you go back just one? Another comment or follow up to what Michael was just saying is that coming in from lateral to anterior is great, but also the more proximal you are, the easier they are to separate. So, if you start right down at the perineum, they're going to be a little bit harder to separate than if you get a little bit higher up and then come from Proximal to distal. And, and that's, um, I, I, I think that that's a really nice place to find the right plane. Is on the, is on the posterior wall. You lift up that fascia and then you come around lateral. So I think that's a very good point. So, I have a question. Do you do this primarily without a colostomy? Yes, yes, I talked about that earlier. I personally would do a vestibular repair primary without a colostomy, either newborn or a repair in the next 3 or 4 months, depending on the child's condition, but I can't criticize someone who wants to have a diversion in place. My advice if you want to Try to do this primarily. You may want to do it primarily with a diversion at the same time and then a colostomy closure. I don't think these patients need a colostomy in the newborn period and then a repair and then a colostomy closure. And if you do it primarily, how long do you put the patients on NPO, I mean, How long? That's a good question. All right, let's poll the audience for that one. So, if we do a primary repair with no colostomy, vestibular fistula. Let's do it both ways. Newborn, newborn vestibular no colostomy, who feeds the patient in 4 days or less? Who waits greater than 4 days? A is 4 days or less food. B is 5 or more days. So, if, if it's a nice wound, otherwise you go longer. I can't do it. Vicky, are you keeping up? Look at that. You do the blood. So, my personal practice is I wait, um, until the perineal body is healed, which usually is around day 6 or 7. Yeah. And I think that many people think that's radical. And again, I admit that is based on my bias of having to do a lot of redos, and in large part the redos are in patients that were fed early. And again there's no science behind what I'm saying, and I admit that, but I believe if you are watching the perineal body carefully, you have a way to intervene without a dehiscence. You can actually take the patient back to the operating room on day 6 or 7 and re-suture the perineal body. As opposed to a patient who was fed, was sent home, and then no one's looking, they come to clinic at 3 or 4 weeks and the perineal body has fallen apart. I, I, uh, uh, I know this is a bit of a controversy. By the way, in many parts of the world that insist on never keeping people NPO because they don't have Hyper-al, what I've tended to use is 10% dextrose, which they do have, and only use Hyperal if there's been more than 7 days NPO. And when I started to do that a few years ago, a lot of my colleagues around the world were very happy because it meant that they could try an NPO period because they have D10, they just don't have hyper. I wouldn't do that in under 1 or in a not so greatly nourished child, but in a healthy, robust kid, I would definitely do that. So this is a bit of a controversy, but any, there's a comment from Todd, actually a comment from me. I just throughout the whole morning here we've heard so many things. That you have a bias on that someone else has a bias on and, um, you know, how much dissection for the laparoscopy minimal or just pull it through the cutback, the when to feed and we keep saying there's no science, it's your experiences, it's what you've seen, but you are a referral center. Why not start doing prospective randomized trials, or are you so convinced by your, um, anecdotes that you don't even feel comfortable doing a prospective trial? I think, I think there are a number of opportunities for a prospective trial, but there are a lot of situations where you really can't do that. I don't know, maybe only you could because you have enough cases to do it. No, what we, we recently did, we had an, uh, an abstract in the episode last year. We did a systematic review on the perioperative nutrition, and if you look at literature. Um, it's all retrospective, but actually giving early enteral nutrition seems to be better than later nutrition, just as an adult surgery has been proven as well. The problem is they're all retrospective studies. If you look at the, if you look at the, you score them on quality, they're all poor quality. So what we need, maybe not need is just a prospective study, but a good follow-up study, good follow-up cohort studies on the outcome is the first thing we should do. The second thing is, are you willing to Have to change good results into uh you need a good power analysis to do it and this will have to be a very large multi-center trial, so the evidence is very difficult to get, but I think you could start with a good Perspective study and most studies are all and about 1000 patients have been studied, but they're all retrospective and bad quality studies. I completely agree and I just have always thought when I look at Mark and I see him as an example of a place that's a referral center, it's so difficult to get good data in pediatric surgery and there are a few places where we actually have a center that has enough patients to actually get to it, but that's going to mean that the person there might have to do what they're not comfortable doing. In a prospective randomized trial, so I, I, I, I want to respond to that and then I'm going to have my colleague Kate Deans who's really uh with Pete, the expert in this area, and I can tell you one of the major deficiencies I felt in my previous practice was this exact detail because I, um, as one of my professors like to say, the, the, the plural of anecdote is not data. Right? So, um, we as surgeons deal with anecdote a lot and sometimes we have a lot of anecdote and then we get biased. Um, one of the cool things about getting together like this is, and I know it's frustrating, but people have to find their own way sometimes. There aren't protocols for everything. Even appendicitis now, the protocol is changing, right? So as a surgeon you have to have a feeling and you have to do it the way you're used to and feel like you're giving your patient a good result. But one of the clear deficiencies in my opinion in colorectal was exactly this point. And one of the reasons why I've come to try to collaborate on this exact topic is for is to do better in this, in this area, because I think, I think the technique is pretty clear. We know how to do it well. We know how to not do it well. Now the question is which, which parts have some variability and which is better for which scientific reason. So with that intro, maybe Kate could make a comment. Um, that's a great question. I think your observation was similar to mine that we're talking a lot about anecdotal things, and we've seen from audience response and through Globalcast that we have a lot of variability in what we do, what we recommend, how we screen, all of those things. Unfortunately, like all things in pediatric surgery, we're talking about rarity. Diseases and rare diseases are very difficult to study in clinical trials, because the more institutions you introduce, the more variability you introduce, the harder the statistical approach becomes. So there is um a concept which is about 10 years old, which we're going to be talking about tomorrow in the lunch session, which is called a rapid learning healthcare system. And it allows you to continually accrue your experience and perform statistical modeling rapidly. So you get real-time point of care results to the patient who's right in front of you to answer some of their questions about prediction or a choice of two procedures or two approaches. So we're gonna have a little more conversation about that tomorrow. Mark, could you just comment on your primary, uh, repairs without aversion, your, uh, bowel prep? Sure, yes, so, um, in the newborn period, we don't, uh, bowel prep. I don't bowel prep them, but if they're delayed repair, I do a full, uh, go lightly, um, bowel prep until the effluence is so clear that the resident can drink it. Um, I'm, I'm just kidding, we don't make our residents do that. Um, but, uh, um, and then, um, plus or minus oral antibiotics. I know, uh, lately it's been shown that oral antibiotics may be, uh, of an advantage, and that is our, we have a sort of bowel prep routine that all bowel preps are done the same way. So we actually do that here. I'm not convinced that that is absolutely vital, but we definitely, we do it. Um, and the patient comes in the day before. They come to surgery. So, this baby for today, for example, uh, had a full bowel prep last night, um, and is going to get surgery today. We'll get a PICC line. Um, we'll be on, um, because it's a baby, will be on Hyperal and in 7 days, so next, uh, Tuesday afternoon, we will, we will take a very careful look at the perineum, and if the perineal body is socked in and, Good healing, the baby will be fed and discharged, which is the vast, vast majority of the situation, and on occasion we start to see that the perineal body is a little separated, maybe once or twice a year this happens, and then we take the patient back to the operating room and put some reinforcing. Perineal body stitches and of course and this hasn't happened to me but if the perineal body falls apart then they need to be diverted and I think that technique has avoided lots and lots of diversions that probably would have been needed in the past. The alternative approach is to Do a sub, a different bowel prep than that or no bowel prep at all. Feed the patient early and send them home. And I think a number of those patients, and again I have no data to support this other than the anecdote of seeing redos. A lot of those patients are falling apart at home and no one knows because no one looks and then whenever they come back to clinic, perineal body's gone, or 3 months later perineal body's gone or no one ever notices and then they can't potty train at age 4 and in fact there's no perineal body. So this again, this technique has come out of, out of, you know, learning how to do it to try to try to improve that result. And during the 7 days NPO, do you keep a urethra catheter? A what? Oh no, I don't use a Foley at all. Uh, um, uh, for those in the audience, so vestibular repair, Foley A, no Foley B, or female perineal for that matter. Always use a Foley in the case. Never use a Foley. I can keep it. I keep it. It's a study. Still moisture. Mhm Silver split. Jonathan, do you use a Foley catheter? I'm afraid I do. Me too. There's nothing wrong. Nothing wrong with it. I just don't think, I don't think urine leaking on the perineum is a big deal, but there's nothing wrong with it. I think the, the bias or the prejudice that that that I've had comes from. The idea of keeping um alkaline urine away from the wound, um, I just don't like the idea of that on there. I don't know what BXO exactly is, but I don't want the idea of, of having a fresh wound being bathed in something could go either way. I personally don't, uh, don't, don't use a Foley.
