Colorectal Quiz: Episode 40 - Complex Female ARM

In rare circumstances when laparoscopy reveals a blind-ending colon with no distal segment visible, an end colostomy should be created rather than a divided colostomy to preserve blood supply to the distal rectum.

The only potential benefit of a divided colostomy in a blind-ending colon scenario is protecting the ultimate rectal repair, but this risks the blood supply to the distal rectum.

A single perineal orifice must be classified as a cloaca even when it appears as a normal-sized introitus rather than the typical tiny hole.

Laparoscopic colostomy creation has the advantage of potentially identifying incidental findings like malrotation that would be missed with a standard left lower quadrant approach.

The anatomy in this case is similar to Mayer-Rokitansky-Küster-Hauser syndrome in that there are ovaries, scrawny little tubes (probably remnants), and no midline structure at all.

It is extremely rare to have a Mayer-Rokitansky-like presentation associated with a cloaca; there is almost always something gynecologic (Müllerian) connected to the common channel.

Mayer-Rokitansky-like anatomy can occur with an anorectal malformation.

The more common scenario of Mayer-Rokitansky with anorectal malformation is a recto-vestibular fistula with a completely normal urethra but no vagina in between—this is called recto-vestibular fistula with distal vaginal atresia, where the rectum ends as a fistula in the vestibule.

In this case, what is particularly odd is that the rectum ends blind and quite high in the pelvis, not reachable through a posterior sagittal incision.

The sacrum in this case appears very foreshortened, with everything below a certain level appearing not to have developed—a form of caudal regression.

The decision not to divert after this repair was considered safe because there is a colocolonic anastomosis at the colostomy closure site and only an anoplasty with a couple of posterior sutures, unlike Hirschsprung disease where non-relaxing sphincters could cause backup pressure and blow out the anastomosis.

If diversion had been chosen in this case, an ileostomy would have been the preferred choice.

Colonic neovaginas are not great for patients 20 years down the road and should be avoided.

In most cloacas, the native vagina should be able to reach and vaginal replacement should be avoided.

The introitus in this case is potentially dilatable in the future, which can provide a very functional vagina.

One option for vaginal reconstruction is to open the introital area and lay in a buccal graft.

In 20 years or perhaps even shorter, tissue engineering options for vaginal reconstruction will likely be available.

People are currently taking vaginal cells and growing them for tissue engineering applications.

In current practice, one can completely avoid a vaginal replacement in these cases.

If there is no immediate problem requiring vaginal reconstruction, it is better not to go in and remove tissue (bowel or graft) unnecessarily.

In this case, the colon should not be used for vaginal replacement due to concerns about its blood supply, which was likely compromised by the original divided stoma procedure.

In this patient, there is a real estate problem within the introitus because it is currently encompassed by the urethra, requiring some form of urethroplasty to make room for any future vaginal reconstruction while preserving the perineal body.

Vascular anomalies associated with anorectal malformations have not been much written about in the literature.

There can be odd formations of pelvic anatomic blood vessels in anorectal malformations, such as an aberrant external iliac artery that loops up within the abdominal wall resembling an obliterated umbilical artery but actually supplying an extremity.

Surgeons are judged by what they are willing to stop for; when uncertain about anatomy, it is wise to stop, get more information or help, rather than plow through.