# Posterior Sagittal Anorectaplasty-Female Part III: 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 III of a posterior sagittal anorectoplasty in a female.

Type: video · 30 min · posted 2019-01-11
Canonical: https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092

## Chapters
- [0:05](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=5) Intraoperative Discovery and Initial Management
- [7:05](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=425) Neovagina Construction Rationale
- [15:00](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=900) Technical Execution and Anatomic Considerations
- [23:20](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=1400) Long-term Management and Case Reflection

## Statements
- "63% of respondents favored protective colostomy, 36% did not" (opinion) [0:14](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=14)
- "Colon is preferred over small bowel for neovagina due to more robust blood supply; small bowel mesentery is tenuous" — Marc Levitt (clinical) [2:12](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=132)
- "Small bowel does not produce less mucus than colon for vaginoplasty" — Marc Levitt (clinical) [2:07](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=127)
- "Purpose of neovagina is for long-term sexual function and menstruation, potentially for conception if cervix is competent" — Raj (clinical) [6:20](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=380)
- "7-8 centimeters is used for bowel segment length because that approximates normal vaginal length in a baby" — Marc Levitt (clinical) [7:56](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=476)
- "There is no science behind the 7-8 cm vaginal length measurement" — Marc Levitt (opinion) [8:06](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=486)
- "Family agreed to leave structures that did not need to be removed, given uncertainty about future reproductive potential" — Marc Levitt (clinical) [10:09](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=609)
- "Uterine transplantation is now a successful procedure (referenced as recent development)" — Marc Levitt (clinical) [10:37](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=637)
- "Neovagina should be tacked to pelvic fascia or posterior bladder to allow it to grow and lengthen into pelvis" — Marc Levitt (clinical) [11:06](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=666)
- "Vaginal dilation is not performed post-operatively; some patients will need introitoplasty later" — Marc Levitt (clinical) [11:58](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=718)
- "Pelvic ultrasound and examination under anesthesia with vaginoscopy should be performed 6 months after breast budding" — Marc Levitt (guideline) [12:24](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=744)
- "If no cervix is found, decision must be made whether to empirically remove uterus or wait for trouble" — Marc Levitt (clinical) [13:55](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=835)
- "Surgeon has patients without cervix: one had two episodes of pelvic inflammatory disease requiring removal, another has been asymptomatic" — Marc Levitt (clinical) [14:17](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=857)
- "Pelvic MRI in infants has limited utility for identifying vaginal lumen unless there is hematocolpos or hydrocolpos" — Marc Levitt (clinical) [24:51](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=1491)
- "MRI can frequently identify fallopian tubes, ovaries, and uterine anatomy but has low confidence for vaginal lumen assessment in young patients" — Marc Levitt (clinical) [25:32](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=1532)
- "Preoperative workup would not have been changed; imaging did not hint at Müllerian anomaly and office exam appeared gynecologically normal" — Marc Levitt (opinion) [27:31](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=1651)
- "Independent examination under anesthesia would not be performed; patient should be examined at time of PSARP" — Marc Levitt (guideline) [27:39](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=1659)
- "Neovagina is already tethered to patient's proximal vagina, eliminating need for separate tacking to bladder" — Marc Levitt (clinical) [29:20](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-female-part-iii-pediatric-colorectal-1092?t=1760)

## Transcript
Uh You feel the bump? So 63% said a protective colostomy. And 36% said no protective colostomy. Does anybody want to voice their opinion on why they would not do a protective colostomy for the 36%? Why do they think it's unnecessary. OK, can everyone see well? Oh What You Yes. So, by the way, look at this. This is cool. Forces. So this is a like a hymen, see. OK, let's get the urine. OK. So this is like a hymen. Let's use it. Can I have you hold opposite me on the other side of it, battery. I Everyone see OK? Yes. Hey Mark, this is, this is Todd. We have a question from Pueblo, Mexico. They wanna know if, if you could answer about the use of the decision of the conduit of do you ever use small bowel for a neovagina versus colon? Yeah, I think it's a good question. I prefer colon, and I'm curious to know what everyone else in the room who does this. Specifically, they wanted to talk about, they said that there's less mucus. Less mucus with small bowel, right. I don't think that's the case. I find the small bowel mesentery a bit tenuous. So I prefer, I think the colon is a little bit more robust. From a blood supply point of view. 1 o'clock. I put a stitch in before I completed the closure of the stabilizer it wouldn't. Do that. Thanks lottery. The rest of the staple line is now off. Nice, nice bleeding, huh? OK, good. I think. And there all that. OK. You know, All Oh. I'm gonna loosen this a little bit. So what are now our landmarks? Say we have enough vagina. It is. Looking at this labial fold. Also, we need to know where the anterior limit of the sphincter is. Decide how much perineal body you can make. OK. Ah Anyone have any thoughts about that? And to decide how much of an intro is to me. Doctor Sakar. Are you awake? Well, you are now. Um, but, what are you thinking about? What's the purpose of the neo vagina? Hold on, let me get you the microphone. I'm going to put Raj on the phone so you can beat on him a little bit, sort of simulate the true OR experience for everyone. So, uh, the purpose for the neovagina, uh, in this case will just be for, uh, long term for sexual function. That's really it's uh sole purpose, uh, for this, uh, for this and then also for menstruation. Well, well, maybe she could, uh, um, conceive a baby, uh, if the, if we believe the cervix to be, uh, competent in this case. Which is to be determined. Right. I think we're almost there. So Mark, where does the 7 to 8 centimeters come from for the segment of bow? Why not 6 or 3 or 10? Where does that come from? Um, I don't know what, what, uh, what a normal vaginal length would probably be the date of someone this age. Uh, Jerry has an opinion about vaginal length. I think she just stepped out for a sec. How about Kate, Kate McCracken there? They went out together. I think if you're cutting into the uterus, you should answer that question. Well, I just normally in a baby do about 78 centimeters because that's what a normal vaginal length looks like in a. OK. I think there's no science behind that at all. OK, so let's connect the dots here. Oh behind me uh. Try not to leave the colostomy. How long would you leave the Foley? And urine all over the place, that the, these patients often have a very large urethra. OK. Yeah. Right, so whenroitis is done. You have a bit? Mark, how did the conversation with the family go? Did, did you have a chance to talk to them? Yeah, well. Um, I think they, you know, obviously. Very new information from them. I would never have a conversation of this type. Every perineal vestibular fistula. Right so the screen is rare. But uh yeah, they were cool and they agreed that they wanted to leave structures that did not need to be removed today. Uh, in fact, I agree cause I don't know what it's gonna be. I don't know what's gonna happen here. Our technology and our ability to Thing the uteruses I mean, who would have thought a year ago that there would be such a thing as a uterine transplantation. The successful. Hey, Mark, uh, Michael Rawlins, um, are you, what techniques are you, uh, are you using or, or what are you thinking about to prevent this, uh, prolapse of this, uh, neovagina in the future? Are you, are you going to tack this in some way in the pelvis or? Yes, that's a very good question and the answer is yes. I would either tack it to the uh pelvic fascia or to the posterior uh bladder. So that it grows with her lengthens into her pelvis. All right, we'll need the stimulator soon to figure out where the anterior is. Mark, we have a couple more questions for you. I'm repair. What was that, Kate? Sorry. No. Don't worry about it. So then what do you tell these families for the expected gynecologic follow up when they come back to the office? Well, I, I don't dilate the, I don't dilate these vaginas. And I anticipate that a certain percentage of them will need a little bit of an internalplasty later, but I think it's a lot of torture to make them go through vaginal dilations. Um, and then obviously we need to, um, 6 months after breast budding, you need to be very aware of the Mullerian structures. See if there's dilation of structures and see if she can menstruate through this thing. And probably given the anatomy we just set up, I would probably scope her with Jerry and um figure out if in fact there's a cervix and things are a lot bigger. And uh Go from there and then hopefully, hopefully she doesn't get an infection. Do you do a pelvic ultrasound at that point? Pelvic ultrasound. And decide whether they're dilating up with nowhere to go for the blood. Mark, at what point would you do a vaginoscopy, and if you found that there was no cervix, what would you advise or and or do? Yeah, I think that's the, I mean that's the that is the key question who, who is that? Spike. You're, you're you're a former senior. Like Irish, just so everyone knows, we were cofellows together. Everything I am today is because of that influence. He's the one I should blame. He's one of my one of my favorite people in the world. Um, so I think after breast budding, would be the time for a pelvic ultrasound and an examination under anesthesia and a vaginoscopy. And if There's no cervix, then we have a tough decision to make. Whether to empirically remove it, so here's the adroitis. Ethra. And the perineal body. To empirically remove it or just wait for trouble. I have, I have a couple of these patients that I follow that don't have a cervix at all. I think this patient has a bit of a cervix and, uh, in one of them, she had two TID episodes and we removed. And the other one, she's been perfectly fine with no episodes. Can I have a stimulator? Are you happy with the length of the perineal body for Those of you And I'm gonna pull that up in the abdomen a little bit so I don't take out as much rectum there. OK, let's simulate that I think we, I think we found the right spot here. And then I'm just gonna show you, can you cut here. All right, stimulator. You humidity got, can you roll that over. It should work better now that it's open. I think There we go. You can see very nicely, it goes from here to here, right? Everyone agree? Mark, can you touch it again posteriorly, make sure it looks like it's in the center and not in the anterior aspect. There's, there's the anterior right here and there's the posterior right here. I don't think we see any posterior contraction there. OK, see you later. There it is, yep, thank you. All right, so let's push this in a little bit. Just like this, I want to put a stitch, and I have the lungstar pin, two of them. All right, I'm gonna simulate the posterior sagit incision a little bit without flipping the baby. And uh 4 vital. Here is the posterior edge of the muscle complex here, but of course we're in uh. Where you find OK, so this is uh what what a what a laparoscopy main Par would look like very much so let's. Let's wait on that mosquito, the mosquito. Stitch Eleva or visible here, here's. Oh Oh this. Hey Mark, Yes, this is Todd. Um, so we have a question from Mexico again. It's actually pretty interesting. So when you did that cysto, did you see the ureteral orifices? The rear arteries, yes, you did. Yes, but we were upside down. They were just wondering that there's continued urine coming from around the foley and it could be, could it be ectopic because the, uh, urethra is bigger than the foley we have used, OK. We could put in a bigger Foley, but All right, so there's our planned nanoplasty. I do one more. Here. So I'm just, what I'm gonna do is I'm gonna finish this anoplasty. Then I'm gonna ask my partners here, uh, Pete and, uh, Richard to undo the colocolonic anastomosis. And that close and in the meantime, once the angioplasty is done, let's finish radiology and then we'll come do um. Uh, problematic cases, Mark, we're finished with radiology. Oh really? Yeah, it was pretty much right on time. OK, great. So right audience. Yeah. I think this is what what Keith was talking about. There's a little bit of a dente line. Is Keith there? I am. Keith Gorges in there. I'm cringing. Look at that. So the question is why do we cut it out? I'm not cutting it out. I'm saving it. Oh great, I'm showing it to you. that I'm saving. I Wanna do a little more perineal body. I thought you'd be proud of me. All right, I am. I want you to be proud of me. You know, Doctor Jorgeson was teaching the laparostomy course when I was a fellow. I still remember. Yeah? And how? Actually, no, Mark, I thought you were a great learner. You had a good background. And you really want, you soaked it up like a sponge. I, I remember that very fondly, that course. We're doing a lab tomorrow, Keith. Have you done a, have you done a laparoscopic Hirschrun's in a pig transanal? They always used to save the anal part for me. It's amazing how good a model it is I have been. Really, really good demonstration of both the Swenson and a swab. You know, OK, it's. You see those columns? Yeah, it's so cool. a little bit You know, Cut it out. Mark, this is Todd. I just have to say, I, this is definitely an unexpected detour, but I have to say I am so happy that I got to see this case. This is, this is good. I'm really happy you're here. Are you happy? I'm happy? Also happy you're happy today. A couple of people are wincing that you're cutting stuff off that they would have left behind. Very little. Give me a break. It's been a rough case. A break that was. I cut out very little of this. She has really good muscles, and she's gonna be good. Any more questions from the fellows to Doctor Levitt before he breaks scrub and comes down here? There's a couple of minutes left in there and he's headed down. Any questions? Just wanna finish this uh setting up this anoplasty and then we can. And cut it and we'll do problematic cases. Is there anything about radiology that. Needed further discussion, broadery? Nope. OK Mark, had you decided to abandon the case today and investigate it radiographically and then perhaps laparoscopically, what, what X-rays would you have gotten? Well, you know, one can do an MRI. Is is Brent still there, our MRI expert? I, I don't think it sees the. Anatomy very well in a baby this size. But uh, you know, we can do it pre-surgical was that structures are not dilated, that's the problem. Well, sorry, was the question pre-surgical MRI that Brent? Yes. Um, you know, the validity of a pelvic MRI to look at gynecologic structures in a baby like this, um, I, I'd say every time, regardless of what the truth is, I struggle with whether or not there's a vaginal lumen, um, unless there is clearly a, uh, hematoculpos or a hydroculpos, um, uh, and. Uh, so I, I, I find it, it's, it's less helpful than I would love it to be. It's always promises to be much better than it is, and. The very young patient Yeah, fallopian tubes, ovaries, even the anatomy of the vagina, we can frequently tell, but the presence of, or the uterus, excuse me, but the presence of the vagina and what the lumen of the vagina is like is, um, uh, very challenging, and I, I have very little, uh, confidence in. In MRI in that instance. It's possible to, we're gonna pull up the rectum a little bit. 11 question was, could we, uh, instill or could we cannulate the lumen of the vagina and see better, and I think that's possible, but I'm not sure that there's an advantage in MRI. And one of the problems is once they're in the magnet, keeping the fluid in the vagina. Um, would be quite difficult. Do the anoplasty under a little bit of tension. It's supposed to roll in a little bit and we're gonna also pull it up into the abdomen too so there's no excess. You'll see it's gonna suck in very nicely fish. To the very complicated. Do whatever you want. We can always do Right, I think we're good. What, what else did we do? Did we show uh. Yes we're good. We go to problematic medication. Or I So I just wanna make, make very clear, you guys can still hear me, right? Yes. So I don't think I would have changed a thing. I don't think we would have changed the preoperative workup. I wouldn't do an independent EUA. I would examine the patient at the time of the PSA. One thing I suppose we could have done is quit. And maybe done an MRI or maybe done a laparoscopy. Or maybe done a better scoping rather than one that was upside down. Then I think we would have done the same thing, um, so I think Doctor Curry's point to make sure the fellows have a good plan is to not do this, but to really get all their ducks in a row before they start a case like this. And um but I still think we would have ended up doing the same thing. None of the imaging hinted at this, and even the office exam looked amazingly normal from a, a gynecologic point of view. So, I don't think I would have known anything more than I knew today. All right, so Mark, we have another question. Thanks. I'm Amber Travis from Eugene, Oregon, and I just had a question about post-op pain control and if you would do a cuddle on this, kiddo. Oh, what's the anesthesia plan? Yeah, we're, we're gonna do MCA, um, patient controlled analgesia. I did the one on one. He's here's the, here it is. Here's the vagina, but it's tacked because it's connected to the neoagina, see. So it is already tethered into the abdomen. If this was to answer Michael Rollins's question, whose hand is that? My hand, sorry to answer Michael Rollins's question, if this wasn't connected to the neo to the, uh, proximal vagina, I would tack it right here to the back of the bladder, but I don't need to do that because it's tethered to the, um, to the patient's vagina. OK. Here is distal go through. Here is proximal. Those two ends go together and you can. a little I Good, thank you. I'm gonna come down. I'm gonna have pizza and Richard finish. OK, thank

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Not medical advice · citation policy: https://library.globalcastmd.com/ai