# Posterior Sagittal Anorectaplasty-Female Part I: Pediatric Colorectal... — GCMD Library Drs Marc Levitt, Rama Jayanthi, Carlo Di Lorenzo, and Karen Diefenbach host a half day symposiumhighlighting new concepts and controversies in pediatric colorectal anomalies, primarily focusing on anorectal malformations. Here is part I of a posterior sagittal anorectoplasty in a female. Type: video · 28 min · posted 2019-01-11 Canonical: https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094 ## Chapters - [0:00](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=0) Initial examination and discovery of absent vagina - [4:50](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=290) Intraoperative decision-making and cystoscopy - [10:30](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=630) Surgical technique and nerve stimulation - [16:55](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=1015) Cystoscopy findings - [21:13](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=1273) Management debate and recommendations ## Statements - "Total body prep from nipples to toes is performed in supine position for these patients" (clinical) [2:06](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=126) - "Foley catheter is typically placed in supine position before flipping patient prone over bump" (clinical) [2:21](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=141) - "In a baby this small, MRI pelvis has difficulty delineating uterus and ovaries" — Mark (clinical) [3:46](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=226) - "Neonatal ultrasound was performed and was normal but did not specifically show vagina" (clinical) [4:29](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=269) - "Cost-effective nerve stimulation uses anesthesia train-of-four box instead of dedicated pena stimulator" (clinical) [8:08](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=488) - "With train-of-four stimulator, one probe must be grounded on wet skin while touching with the other probe" (clinical) [8:35](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=515) - "Lateral dissection defines the anterior plane in posterior sagittal approach" — Mark (clinical) [15:24](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=924) - "In absent vagina situations, the urethra is always found to be quite big" — Mark (clinical) [19:29](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=1169) - "There is typically a thick wall between rectum and urethra in absent vagina situations" — Mark (clinical) [20:53](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=1253) - "The distal rectum has value for continence in patients with good potential for bowel control" — Mark (clinical) [26:26](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=1586) - "Neovaginal reconstruction timing depends on presence of uterus - if present, connection to outside needed before menstruation" — Tony Khoury (clinical) [23:30](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=1410) - "Imaging may not be extremely helpful at this age due to very small structures" — Mark (clinical) [24:39](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=1479) - "Upper vagina is unlikely to be present when lower vagina is absent, though possible" — Mark (clinical) [25:09](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=1509) - "Would not perform separate EUA in newborn primary anorectal malformation case - would do EUA at time of repair" — Mark (opinion) [27:22](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=1642) - "Renal workup for this patient was normal" (clinical) [12:18](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=738) - "Patient has good quality sacrum" — Mark (clinical) [12:37](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=757) - "In girls without vagina, must be more careful about bladder and urethra during dissection" (clinical) [14:05](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-i-pediatric-colorectal-1094?t=845) ## Transcript All right, so this is very interesting. I have a catheter. What does everybody think? I'm putting a Foley in. I thought you didn't put Foley's in. I. I'm gonna tell you why in a second. It's OK. We never have strictures either. OK. No comment. This is, this is urethra. And urethra here and this is what we thought was vagina. I can't find anything. Everyone see that? Yes. Are you going to try to Are you gonna try to pass a catheter there or just your forceps? Trying and I'm not finding a woman. Always surprises. But there's no vagina here. Isn't that incredible? It looks very, very normal. I think this is. Very good representation. That OK. What I surgery. So just for the fellows in the audience while he's um figuring that out, one of the things that we do for these patients in the OR is we do a total body prep for them. So they're prepped from the nipples to the toes in the supine position. A Foley catheter is typically placed at that point and then they're flipped prone and put over a bump. Uh, and that allows us to secure snaps and other retraction devices to the drapes while we're working. And allows us to flip back and forth if we need to. No wonder. Yeah. Is the bed. That's very typical. So, amazingly, of course, we tried to take, we tried to pick a very typical case to illustrate the principles of a, a repair of a perineal disk. And this is normal urethra here and what looked a lot like a normal hymen. But I'm expecting and I don't find any looming here. Sort of big urethra, see. I think there's no vagina here. All right, can I have a 50s soaps? So what should we do? What should we do? So if we had an MRI of the pelvis preoperatively like we do with a lot of our arm patients and screening, we would potentially be able to see whether the uterus and the ovaries are there. If we didn't, unfortunately in a baby this small, it's very hard to delineate those structures. I think this is coming as a bit of a surprise. Mark, we have a question about why you're not, uh, doing a cystoscopy to see if there's a your genital sinus. Doctor Canning thinks you need to give Rama a call. And is there a prenatal ultrasound? I was always invited. We have a question about whether or not there was a neonatal ultrasound performed. Yes, there was. Was normal. The question is, did it show a vagina? Are you referring to a perineal ultrasound or a pelvic ultrasound? Correct. No, it did not show that. No, it did not show that. I guess you can hear him. I'm sorry, can you repeat that? To. Mosquito. OK, can I have a uh wheatlander? Oh, this is why you have to look. I can have a lone star pin. So Mark, why did you uh opt not to do cystoscopy right now? Well, I'm thinking about whether to do cystoscopy right now. OK. I think you're thinking about never letting me moderate again. That's probably what you're thinking about. No, I'm not. I mean, we could put a cystoscope in here. How hard would it be to set that up? Forceps? In this position. I think this is a normal urethra. I'm pretty sure that the vagina, yeah, the urethra is sort of big. Mhm. It's very typical of one of these malformations. Trying to figure it out. But this area here. Where the vagina normally is, I don't see much of anything. Now we have a difficult decision on our hands of whether to. Use the rectum as rectum or make a neoagina here. Can he be doing the right thing. Any suggestions? Paula has a suggestion, just a sec. The Italians want you to fix the rectum, bring the anus down and leave the vagina for later. 10 years. OK, anyone else? Laparoscopy. Marked diagnostic laparoscopy. Yeah, I think, I think that's important because there could, there could be an upper vagina. But what we can certainly do is take care of the rectum. Rectum can be moved back to within the sphincter. By the way, do you have the stimulator? Just. This is the new way we've been doing the stimulator, which is a lot less expensive. You see these, these guys. OK. I know So this is, uh, these probes are connected to the anesthesia stimulator machine or, uh, the nerve stimulator. all the way. So you have to, as opposed to the, the, the pea stimulator, um, in this one you have to ground. One of the probes onto the skin, make it wet, and then touch with the other one. And Mark, you're using the trainer 4 box from the anesthesiologist, right? Correct. It's outside. It's outside. You can see it. So this is a much less expensive way of doing this. Here's the center. You'll see it much better when it's when it's open. All right, let's start taking care of the rest. Can I have the cautery? Oh yeah. Mark, could you put the image closer to the middle of the clock for us? You're up at about one o'clock on our screen. Sorry. Thank you. We have a little bit more trend down. I would, I would, I wouldn't need to. or Which thing to do the cyst you do the cystoscopy. And a full full I wish uh. Mark, there are some questions as to why you're proceeding, like are there concerns right now? What? You don't want me to continue? Well, What do you want me to do? We'll fix, we'll fix, we'll just find the, we'll fix the rectum. We're gonna get the cystoscope ready. And then we'll figure out what needs to be done and if we can, we can always laparoscope her later and do a vaginal replacement between the urethra and the vagina at another time as Paula has suggested. Alternatively, we could make this distal rectum, uh, the neovagina. I'm happy to hear your suggestions. I just don't see a vaginal opening at all, and I think the cystoscopy is gonna confirm that. I No. I have a Lone Star pen. Well, I've been using these when the incision is relatively short and it doesn't really accommodate the wheat lander nicely. over They're really helpful. So. That For. I'll Hey, what are people saying? They don't want me to do this? They left I First course, a miserable failure. Everyone left. No. Shain. Can I have the long tar pen? Perfect. Kira. I know about the baby. A. Mark, can you tell us a little bit about the um renal workup for this patient? Was the urologic workup done prior? Yes. Normal. Normal. And how about the quality of the sacrum? And the sacral ratio, do you know that? Um. It's a good sacrum, I'm just not recalling right now the numbers. May I have a long star pin? Mhm. I'm recalling the, the, the, uh, the number. That Turn down the coag a little bit, please. A little bit too hot. That is perfect. So for the 2nd-year fellows in the room, let's see, I only know one, Raj, are you here, Raj? Somewhere? Oh, there you are. I can pick on you, perfect. Right, if there's no vagina. What do you have to be worried about at this dissection a little bit more than you would. It's a girl. Bladder, what else? The urethra, the urethra, urethra. I Yeah, parastatal fibers are being pointed out. That's right. And there's the issue of rectal status. Try not to make a dumb out of turning it here. Yeah. We're setting up for the system you know. Mark, I see that you're going kind of side to side on the rectum. Can you maybe talk a little bit about your technique and why you're doing that for the fellows? Again, lateral defines the anterior. First step ladders. I want a nice clean. Lateral plane. We're gonna do upside down cystoscopy here. Is it possible to corporately. It's a Is it blurry? So I can't see it, so. Mark, the um incision is a little blurry, but your hands are very clear. Is there any way to change the focus a little bit on the camera, the focal length on the camera? I think it's auto focusing on your big myths there. Is that better? Is that, is that better? No, not really. It's just, it's hard to see the um the details in the. That's worse. I'm sorry. Especially Yeah. The fire on the car that can be turned around. In or out? OK. I. Oh, it's better, thank you. OK, so let's see if we can see a cystoscopic image of what the effect we're dealing with here. I've never seen him not use a Foley catheter. I shouldn't have said that to the microphone. I should have hidden that. Section Are you guys switching over to cystoscopy? Yeah, I don't see an image. And There we go. Get it. I don't see any. I Am I supposed to be able to see something? Hello. I feel like Jerry Springer now. So much We can see the image. It's quite blurry. OK. That's good. So the parents will be happy to hear that. Take out the phone. You can admit it. Bear with us for a little bit, OK? We're switching between, uh, different screens and. Instruments. We'll figure it out. OK. Looks an awful lot like a bladder. Everyone in urology agree but it's upside down. Real orifice. All of these, uh, as the ureterologist, absent vagina situations, I've always found that the urethra is quite big. What are you pointing to this one? So there's no vagina here. There's the collapsing bladder neck. Is Doug Canning satisfied? Well, I think it's there. You just have to find it. He says he thinks it's there, you just have to find it. It might be thinks it's there. It might be too high to climb, but why, why does he think so? You may never invite me here again. I don't, I don't see a vagina. No, I don't know that you'll find it now, but, um, on the ultrasound that you had, you, you could see a vagina on the pelvic ultrasound. I don't think it was really looked for. OK. OK, all right, let's just stop that. All right, let's just see, we shall see. Cover this, but usually what happens is there's a, there's sort of this thick wall between the um rectum and the urethra in these uh absent vagina situations. Yeah, we're done with the system. So what I'm debating is whether to um. Whether to use this as vagina or just make the rectum and then pull through a neovagina. Let's discuss that. Vagina. Is. So any opinions on creating the neo vagina now or doing the pull through and waiting for a new vagina at a later date? Doctor Teitelbaum. Yeah. Uh, my two cents, this is a pretty nice looking perineum, so this is probably a pretty nice anal canal, and I'd use it as an anus. It's gonna be a little bit of a pain, but flip the child and take a sigmoid for the, uh, neovagina. I would do the neovagina now. Uh, I, I think you're gonna have to go through a lot of scar tissue. And it won't be 10 years from now because she's 10 years old, it's not an ideal time. I think honestly, it's gonna be 15 to 20 years of age before you would address making a neopagina. Can we do audio response on that. What would you use as the agina forces? Becky, can you do a, um, audience response for that? Let's take a vote and see how many people would create the neovagina now out of this distal portion of rectum. And how many would come back to battle another day. Are you sigmoid? Well, we only have an A and B. We don't have a C. So why don't we do it first? A is neov vagina now, B is neovagina later. I. Oh sorry. Hey Mark, this is uh Tony Khoury. So I, I think we, uh, we need to know a bit more information before a decision is made. So we don't know if she has malarian structures and, if she has a uterus, uh, in there or not. If she has a uterus, then you'll need to connect it to the outside before she starts menstruating, and that determines when you're going to end up doing her, uh, her reconstruction. The other thing just for the trainees standpoint, I mean, you have a lot of experience, so it was easier for you to march on and, and get the case going, um, but for a tra from a trainee standpoint, what advice do you have for them when they're facing exactly this situation? And and how they would, should they stop the case at this point and get the imaging that needs to be done, whether it be an MRI or be a more complex ultrasound, or should they just march on and then figure it out as they go, which is what basically you're doing now? No, I, I would, I would quit. Or maybe just do a diagnostic laparoscopy. We're going to do. By the way, we, we'll probably laparoscope her once to the tack this and then press the phone. I would definitely stop and then do a diagnostic laparoscopy. I don't think imaging is gonna be extremely helpful at this age. It might give you something, but it might not give you anything. The structures are very, very small. We can look into the laparoscopy. And that's all re. This is, this is a meeting, and Tony's point is very well taken. We have to, there could possibly be, although it's unlikely, an upper vagina. Unlikely, usually there's not. S Yes. Mark, we're trying to figure out if we can pull up any of the imaging from PAX, uh, from the ultrasound to see if anything was visible on the ultrasound. We had a couple of requests for that, so we're just working on that on the side. aware of the HIPAA. Yes, I am aware of the HIPAA. I'm trying to reach you. Mark, can you comment on stating that you would consider using the rectum as the neovagina versus a different segment of bowel? Yeah, you see this is a beautiful male vagina this thing. The only issue is that, um, theoretically. It has some value as far as continence and this is a patient with good potential for bowel control and in that regard, it may be worth keeping it as rectum. rectum remains as rectum, neovagina is with a piece of coal. So this may be another opportunity for you to fire me for moderating a session of the course, but let me just say this. Typically in these patients, we do an EUA on a separate day. That's how the clinic is outlined. So we'll see them on a Thursday and then on Friday, we would have done just the EUA and had a chance to do cystoscopy and then the Monday or Tuesday would have been the main OR case where we probably would have planned. Um, maybe a little bit differently and could have taken on some of these suggestions with a diagnostic laparoscopy preceding the posterior sagittal approach. Is that fair, Mark? I would not have done an EUA in a in a newborn like this in a primary case. I think I would have done an EUA in a situation. But not in a newborn. I wouldn't, I wouldn't do a separate. I would do the primary repair. I would do the EUA at the time of the repair, which is essentially what what we're dealing with right now. The question is. Should we just do an EUA and quit and come back another day or proceed? I decided to proceed. But I wouldn't do a separate EUA in a in a straightforward case like this. I would do the EUA at the time of the repair. But as you can see, you know, we examined the patient in clinic and it looked, looked very nice. It looked like a normal vagina, but it obviously didn't have a wo. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai