Mark, hi, it's Don. Um, so the only problem with this case is it's happening during the course. I said that the big problem with the case is it's happening during the course, so it's, it's putting extra pressure on you. So I think, you know, I completely agree with what Dan Teitelbaum said that if you didn't have a course going on right now, you'd probably want to say now's probably the best time to make the. Sorry, can you hear me now? Yeah. So I agree with Dan Teitelbaum that the best time to make the vagina is today. And the, the issues about whether to use what you have in your hand as the new, new vagina or not are that sigmoid colon, if you pull it down, won't for the to the anus, won't function as a rectum. So your choices are to use that piece of rectum as a neovagina, which I've seen Alberto do in this exact same setting during the course, and. You know, it works, but then you have sigmoid colon trying to function as a rectum. It's not a rectum. It doesn't have the same storage qualities and physiologic properties. So you know my bias would be to use that rectum as the rectum and then go and get a piece of sigmoid colon, but what a lot of people are murmuring in the room is we don't know the exact anatomy. So I think, you know, before you cross a bridge before where you don't want to get back from is we need to figure out what the internal anatomy is. In my own personal series, I think I've had 8 patients with a recive vestibular fistula. With no vagina and only one of them turned out to be an imperfect hymen. It actually was a vagina that was an imperfvert hymen, but none of the others had a uterus or fallopian tubes. So I, I would, I would predict that's what you're gonna find. Yeah, I agree. That's the vast majority. This So this is urethra. This is where vagina would be. There's nothing here. OK. This Are you there? Everybody's just enthralled. Very different plane between rectum and urethra without a vagina in the way. It's much thicker. And everyone see this areolar plane. That we're getting to. Yes. Right, so that's the bladder. Mhm Would be such a nice vagina, don't you think? Hey guys, what should we do? So Vicky, why don't we take another audience participation vote of whether to use the rectum for the neovagina or the sigmoid colon. Mark, just so you know, 65% said to do the neovagina now rather than wait. OK. A, A is rectum, B is sigmoid. Which part of the colon should you use to make the neovagina? A rectum, B sigmoid. Spine is OK. By the way, we may be able to see into the abdomen from here. I have a beaver. Wow, I need a camera so I can show you these results. 98% of the people surveyed, of which there were how many voted? Upper left corner. I can't read it. 51 said to use the sigmoid. Only 1.96% said to use the rectum. Now, are you voting, Mark? Do you have a button up there? Right, well, we'll use the sigmoid then. Bigger deeper. I'm very sorry that we didn't have a very typical case to show, but this, this was the mobilization of the rectum. We're ready to make a rectum if we wanted to. Hm. Mark, while you're working, can you, you've gone in and out on the depth on that rectum where you've encountered some fat and dissected a little deeper. Can you just maybe talk to the fellows a little bit about that because sometimes you think you're on the colon and you're not on the colon. Alright, let me show you that here. We don't have to do a lot of mobilization, but you see these guys. Things, vessels, so that means we can get closer. If you see fat you can get closer. Yeah. This Yes, we can see it. Yeah, but I think we're good. If that is in fact rectum and. 98% of people surveyed want this to be a rectum. I suppose we have to make it a rectum, right? That's what God made it into. That's what God made it into. Yes All right, well, there's our space for our neovagina. Good. Mark, Hi, it's uh Jonathan Pierre. Um, I was just wondering, is Jonathan Sutcliffe from England? OK, I'm gonna, I'll try to concentrate so I can understand you. I was just, I was just wondering what the family knew previously and at what stage did you talk to them. Yeah, so what I'm gonna probably do is explain that to them while we do the laparotomy. You know what we could actually do which would be good is why don't we um I'm gonna set up for a laparotomy. To plan to do the neo vagina. We're going to do a total body prep. We're gonna do a total body prep, and then we will come back to you when all of that is set up. And I think what we should do in the meantime is the radiology session if Doctor Bates and Kraus are present. Are they present in the room? They are not present. Oh, there you are. Doctor Bates is not here. All right, can we find him? We can, Karen, find Doctor Bates. All right, so, um, basically I've mobilize this as much as I want to because that's gonna be the rectum right there. If you wanted to use this as vagina, you just keep mobilizing all the way up and then this becomes neovagina and the more proximal portion becomes neorectum. But I'm gonna go with the um with the group because I think this patient has good potential for bowel control and it's an opportunity to show you how to set up a neovagina but we our abdomen is not prepped. Her abdomen is not prepped and we will get to that point. And in the meantime, why don't we get the radiology program set? We just need Kraus and, uh, and Bates to, to work away and then the other members who are on that, on that panel. Would that be OK, Mark, we took another audience participation and we're 98% want coffee and a cookie and 2%. Want to hear radiology right now. So we thought maybe we would do coffee and a cookie while we wait for Doctor Bates. Great. OK, thanks. Bye. Yeah There you go. I really. Prostate cancer. It's prostate, yeah, it's. connect with you. Sorry nurse. Bye. Seriously, I don't know. Test, test. Mark, can you hear me? All right. OK. win. So, um, do you guys have an image? No. No image. I just wanna knock that on you. Yes, well, that's good. Yes, wow, you did a lot. Why didn't you bring us back? Well, I was so interested in hearing what you guys were talking about. All right, can you see? This is the, this is the little uterus. Is, uh, is Jerry in the room? Jerry. Yeah, she's here. All right, Jerry, I need your help. So take a look at this anatomy. This is fallopian tube, ovary, ovary, and tube. You guys see that? Yeah. And then there was this distal vagina. Like this. You see that? Yes, and we're trying to open here and there's no lumen. There's no womb in here. Basically there's no vagina. There is, however. A uterus. You see that? Uh-huh. Alright, so what do we do? So Mark, there's some confusion in the audience. Where was that nubbing of vagina? Why don't we see that from down below? Oh, because it ended blindly in the pelvis in the back of the bladder. That's what we dissected down and we just dissected and dissect it until it ended as a blind little thin membrane and then delivered it up into the abdomen. It's actually quite, quite easy to do that. It went to the back of the bladder and stopped. And obviously there's no connection to the urinary system, so that's why there was no hydrocopos. And that's why it would be very difficult to visualize this on any imaging, MRI or ultrasound. We re-looked at the ultrasound and there's nothing, and I don't think I would have changed anything about what I've done. And I don't, wouldn't have taken the baby for an independent EUA. I just would have made sure to look at the vaginal detroitis at the time of my peace art. And to our surprise, and this won't happen again for 500 cases, there's no vaginal loin. Well, what do you do? So then that's vestibular fistula. With absent vagina, which we started to talk about. So, as Tony Curry suggested, we go into the abdomen and define the anatomy before we do anything. And I'm actually glad we did because even though it's very, very unlikely, I have had situations where this is real vagina. I've had a couple of cases, I think it's 3. We have about 40 of these. And there's a paper about it. There were 3 of them, that this vagina was actually usable as a vaginal pull through. One of them was extremely low and required just about a matroidoplasty, and the other 2 delivered up nicely like this, but then reached the perineum. And then there are some that have lumen, and you can plug it into the neovagina. So we wanna show you how to do the neovagina. But I need some help figuring out to probably have a cervix, Jerry, right, in order to avoid PID, right? So right now for patients, you know, and most of what we know about this is like a congenital cervical agenesis. Uh, there's no evidence that retaining the uterus and connecting to the vagina is helpful. There haven't been successful live births from that, and the problem has been like pyometria and ascending infection. So if we have a uterus that has no cervix, it doesn't really have a whole lot of value. Um, you know, what's the, what's the value of retaining a uterine cavity or mallerian structure is, you know, the value is if it's connected with an outflow tract, and the value is, you know, can it make a baby? So in the absence of a cervix, uh, there's no evidence at this moment that that can be beneficial for making a baby, and there's evidence that it can be harmful in terms of pyometria. Your advice would be to remove that uterine remnant but preserve the ovaries and the fallopian tub. Yes. Well, certainly her ovaries need to keep stay inside of her body because there's no, you know, evidence that those are a problem at all, um. You know, in the absence of cervix, if you feel confident, I mean, in the absence of cervix, there's no, there's no evidence that that's beneficial at this moment today in 2014 that that's beneficial to make a baby. Well, the alternative is we could just close it and maybe you could be put, you could have a baby put in there and then deliver it through a closed uterus with no cervix one day. We just had a uterine transplant. Then I, then I wouldn't, you know, create a passage to for an ascending PID. Um, I like that idea. So you're suggesting to close this lumen, close this opening, leave it as a lumen in there, and then recognize, recognize the possibility that this could, we could be creating a hematoetra situation here. That, that's a tremendous likelihood, I think if it doesn't, if it's not connected to an outflow track is that it's gonna be humanometria at some point in time. But it does buy you some time, uh, for counseling family and, and whatnot, um, but in the absence of a cervix, I don't, I'm not sure creating a, an outflow track is beneficial in terms of making a baby or and it sets it a risk for a pyometria. Alright, so. Let's leave that for a minute. Let's talk about the neovagina. Can everyone see this loop of sigmoid? So, yes, yes. I wanna show, can I have a marking pen? This is a finger breadth, full finger breadth below the pubic bone. And that neovagina would reach, OK, so what I'm thinking about doing Marking pen. Transecting here. And then utilizing this vessel here. As our pedicle and then transecting here. OK. Everyone see that? Mark, there's some concern, it looks a little long. How, how, how big is that segment? Oh, we, no, we, we will, we can take, we want, I want this to be about 7 or 8 centimeters. We can remove some of this but preserve this arcade. See this arcade? Yes. Here's the main vessel, probably left colic. Here's the arcade going down, and we can probably go to about here and then I'll remove this little extra piece that goes right on the bowel wall so we preserve the mesentery. And then the question is, does this get connected to here? All right, so let's do that and then we'll continue with radiology while we're trying to figure out what to do about the uterus. So Mark, real quick, what is the benefit to doing the neovagina now? Why not just stop at this point, have the family discussion. And decide on the vagina at another time. Because I think technically it's the ideal time to do the neovagina when the rectum has been immobilized. I think that would be a mistake. I think it would be a very scarred, it'd be a very scarred perineum to then put a neovagina through. We're here. It's an ideal time to do this. I don't think they're gonna say that they don't want a neovagina. I do agree that there's a bit of a debate what to do with the uterus. We certainly need to get a vagina. And the best time to do it is when there is a a rectum dissected out of the way. All right, good. Now I'll come into the. OK, so we're gonna have, we're gonna set this up. And then we'll go back to radiology. In the meantime, I'm gonna go talk to the family. Jerry, do you want to come up and, uh, and, and come take a look at this in person and let me make this call. She's running out the door right now, excited to come up or to leave. I'm not sure. And OK Anyone else? Doug Canning, opinion? Drama Pretty much radio silence over here. So, by the way, do not use a stapler. We will, we might use a stapler, but then we'll remove the staple line. I don't want to leave a staple on any overgrows. Can I a statement. A blur. Yeah. You. We are going to take off and stabilize, I promise. OK I OK. A drink. I, I don't see any reason to anastomos this bowel to that, and so, but I just wouldn't remove it. You have a lot to discuss with the family, and I wouldn't remove anything at all until you do. OK, I, I, I agree with that, um, and then the, you know, what's the big deal? You laparoscopically remove it if it causes trouble later. OK, so why don't we vote? Option A would be to create the neovagina and do not connect it to the uterus, and option B would create the neovagina and connect it to the uterus with the understanding that there's unlikely to be a cervix present. O. So 25% of how many responded? 60, 60, only 30, so versus 60. No, OK, 32. 25% of 32 people said to remove the uterus and 75% of three quarters said to leave it intact. OK, why don't we get our radiology panel back up here. Do a little more radiology. Everybody take big gulps of their coffee. All right. So, basically, we have found that where I cut, there is aluminum, as I showed you. And Jerry believes, and I'm convinced now that this uterus. Has a cervix too. So what we've decided to do is to plug this in inside the ne vagina. In sort of a a leash regoire technique, so it's sort of dunked inside. And then we're gonna pull this vagina through and the only thing we're really risking by doing that stitch is um the risk of a, of an infection. But I think there's a cervix here. Very confident now that there's a sur we we flushed both sides. And uh there seems to be a server. The worst case scenario is we have to take it out because it has an infection. Mark, what kind of tactile feedback led you to believe there was a cervix there? Was it just a high pressure zone or was the tissue thicker or what about it? I put the forceps on the back of the uterus and couldn't pass it out, but I felt sort of a, a, a firmness like there was a surface as if, as if this was the upper. Vagina that I finally found aluminum for. Very little vagina, but at least some for this thing to drain into. Yeah. Yes, so this thing is gonna drain into this bowel. We're gonna hope for the best, but I agree to not remove anything that doesn't need to be removed. This is a judgment call of connectedness. But I, I think had we connected the part before I started cutting, it would have definitely been blind, but now I found, now I think there's aluminum. You can cut the top one. OK, so here is the Upper vagina, that we think and uterus to neovagina. Maybe one more. Right, so now we're going to pull this through. Huh? OK. this All right, and we have this, this part of the staple line has been removed from this part and then we'll we'll take out the staple line when we're ready to do the neovagina, and I think we should do it something like. That could be like this. OK OK. All right. Let's do that. Let's pull this vagina through. Mark, are you planning on doing a protective colostomy? We're we're debating that as well. So why don't, while you're working on that, why don't we do some audience participation on that? So, for those of you who think we should do a protective colostomy, the vote is A. For those of you who think we do not need to do a protective colostomy, the vote is B. Yeah. That's directly that's goes back so you need to pass. Look down. Bladder. He OK great. Perfect. Mark, can you talk a little bit about the expectation of orientation for the new vaginal pedicle? And the, um, colon pedicle for the neo anus. I don't understand the question. Where is the vaginal neovaginal pedicle gonna lie? Is it gonna lie in the left gutter? Is it gonna lie in the midline in the retroperitoneal space? Passing right here behind. This is the This is the rectum. This is the distal sigmoid, and this is the proximal sigmoid. So it's actually passing through where the bowel will, will be will be united like that. OK. So now we have this. Here's our vagina. I need a uh week manager. Uh You have to see the phone?
