Marc Levitt

1500 timestamped statements across 4 collections — auto-found in recorded discussions, each timestamp jumps to the exact moment.

Colorectal / ARM & Hirschsprung · guest expert Etiologies (Gastroschisis/NEC/Atresia/Volvulus) · guest expert Intestinal Rehab · guest expert Motility / Pseudo-obstruction · guest expert Pediatric Robotic Surgery · episode host Single Ventricle / HLHS · guest expert

Featured diaries

▶ Ep 87 · 9:11
I think the key to deciding whether to dive into a perineon posterior sagittally is where is the rectum? You want to know what structure you will find if you make a posterior sagittal or even a mini posterior sagittal incision. And there is no question in my mind that if I open posterior sagittally here, the first structure I would find would be rectum. Because the danger is that you go in posterior sagittally, you don't know where the rectum is, and you find something midline and white, like the urethra or the bladder neck or the bladder itself. And that's why we do colostomies. And that's why we do distal colostograms. So we know exactly where the rectum is, and we know whether we should approach it perineally or whether we should do it laparoscopically.
quote · Anorectal Malformation
▶ Ep 84 · 2:23
I had a fellow that said, why exactly are you keeping these patients NPO? And I said, well, because I don't want them to stool. Because if they stool, they're more likely to dehisc their perineal body. And the fellow said, you know, they still stool, even if they're NPO. And I said, yes, but not as much. And he said, this was Carlos Reck, who's now the premier colorectal surgeon in Austria. He's in Vienna. He said, I think it's about the same. And we studied it. And Carlos recorded stool output in two groups, NPO for seven days. And we gave them clear liquids. That was our test, clear liquids for seven days. And guess what? Same amount of poop.
quote · Anorectal Malformation
▶ Ep 4 · 21:18
It's fascinating actually that, you know, of those four procedures, the only one that actually leaves behind virtually no Hirschprungs is the Swenson. The suave leaves behind the outer rectal wall. The Duhamel leaves behind the original rectum, and the ravine leaves behind the original rectum as well. Amazingly, many, many of those patients did perfectly well, and I think that has to do with the fact that the ganglionic bowel, if it's good, can overcome a lot.
quote · Appendicitis
▶ Ep 7 · 21:18
It's fascinating actually that, you know, of those four procedures, the only one that actually leaves behind virtually no Hirschprungs is the Swenson. The suave leaves behind the outer rectal wall. The Duhamel leaves behind the original rectum, and the ravine leaves behind the original rectum as well. Amazingly, many, many of those patients did perfectly well, and I think that has to do with the fact that the ganglionic bowel, if it's good, can overcome a lot.
quote · Appendicitis
▶ Ep 28 · 21:18
It's fascinating actually that, you know, of those four procedures, the only one that actually leaves behind virtually no Hirschprungs is the Swenson. The suave leaves behind the outer rectal wall. The Duhamel leaves behind the original rectum, and the ravine leaves behind the original rectum as well. Amazingly, many, many of those patients did perfectly well, and I think that has to do with the fact that the ganglionic bowel, if it's good, can overcome a lot.
quote · Colorectal / ARM & Hirschsprung
▶ Ep 28 · 21:18
It's fascinating actually that, you know, of those four procedures, the only one that actually leaves behind virtually no Hirschprungs is the Swenson. The suave leaves behind the outer rectal wall. The Duhamel leaves behind the original rectum, and the ravine leaves behind the original rectum as well. Amazingly, many, many of those patients did perfectly well, and I think that has to do with the fact that the ganglionic bowel, if it's good, can overcome a lot.
quote · Colorectal / ARM & Hirschsprung

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Anorectal Malformation 986 entries

How I Do It Levitt PSARP

▶ Ep 8 · 0:20
clinical A no-fistula anorectal malformation defect is managed very similarly to a bulbar urethral fistula. ↗
▶ Ep 8 · 0:45
quote Obviously the key to starting any such case is a good imaging study. ↗
▶ Ep 8 · 0:45
clinical The key to starting any anorectal malformation repair is a good imaging study. ↗
▶ Ep 8 · 1:05
clinical Fistula levels can be classified anatomically: bladder neck fistula is at the deltoid level (C), rectoprostatic fistula is at the triceps level (B), and rectobulbar fistula is at the elbow of the urethral curve or distal (A). ↗
▶ Ep 8 · 1:50
clinical It is important to mark the sphincter location before making the posterior sagittal incision because once the incision is made, it is hard to know exactly where the sphincter center is. ↗
▶ Ep 8 · 2:28
clinical The sphincters must be cut perfectly in the midline so that they can be easily reconstructed. ↗
▶ Ep 8 · 2:42
clinical Without a good distal colostogram, the midline whitish structure at the center of the dissection could be the urinary tract rather than the rectum. ↗
▶ Ep 8 · 2:46
quote If you don't have a good distal colostogram, this midline whitish structure could very easily be the urinary tract. ↗
▶ Ep 8 · 3:06
quote You don't want to hurt the urethra. ↗
▶ Ep 8 · 3:21
clinical Lateral dissection should be performed before turning attention anteriorly during rectal mobilization. ↗
▶ Ep 8 · 3:27
quote That is the critical moment. You want to separate the rectum from the urinary tract below without injuring the urinary tract. ↗
▶ Ep 8 · 3:35
clinical The initial anterior dissection to separate rectum from urinary tract is a submucosal dissection for the first few millimeters. ↗
▶ Ep 8 · 3:40
quote Imagine you are literally dropping down the urinary tract as the rectum is lifted up. ↗
▶ Ep 8 · 4:11
quote If you're not sure, go lateral. ↗
▶ Ep 8 · 4:14
quote When you're lateral, any fat you see means you can get closer to the rectum. ↗
▶ Ep 8 · 4:14
clinical During lateral dissection, any fat seen means you can get closer to the rectum safely. ↗
▶ Ep 8 · 4:23
clinical The lower the rectum is positioned, the longer is the common wall between rectum and urinary tract. ↗
▶ Ep 8 · 4:29
opinion A lower rectum is easier to repair in one sense but harder because there is a longer dissection adjacent to the urethra. ↗
▶ Ep 8 · 4:38
opinion A rectum at the bulbar level is too low to approach laparoscopically and is much safer to approach posterior sagittally. ↗
▶ Ep 8 · 4:41
quote That is way too low in my opinion to approach laparoscopically, much safer to approach such an operation posterior sagittally. ↗
▶ Ep 8 · 4:51
clinical Approaching a low rectum laparoscopically risks leaving behind distal rectum, a remnant of the urethral fistula, or a roof. ↗
▶ Ep 8 · 5:13
quote If you see fat, you can get closer. ↗
▶ Ep 8 · 5:16
clinical The rectum must be in the correct dissection plane or it will not mobilize properly. ↗
▶ Ep 8 · 5:16
quote You must be in the correct plane, otherwise the rectum does not mobilize. ↗
▶ Ep 8 · 5:44
clinical When closing the muscle complex, taking a bite of the rectum helps to avoid prolapse. ↗
▶ Ep 8 · 5:54
clinical The rectum should lie adjacent to, not constricted by, the muscle complex. ↗
▶ Ep 8 · 6:15
clinical As much rectum as possible should be preserved during the repair. ↗
▶ Ep 8 · 6:32
clinical The anoplasty is performed with 16 sutures under slight tension so that when stitches are cut, the rectum will gently retract and appear like a normal anus. ↗
▶ Ep 8 · 6:52
clinical Colostomy closure can take place 2 to 3 months after PSARP once the anus has reached its desired size. ↗
▶ Ep 8 · 6:52
clinical Dilations begin at 2 weeks postoperatively. ↗

Complications of Anorectal Malformations with Dr. Marc Levitt

▶ Ep 15 · 2:57
clinical Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period. ↗
▶ Ep 15 · 3:06
clinical Male babies with perineal fistula may pass meconium and have the malformation go unnoticed, typically presenting in the first year of life with severe constipation. ↗
▶ Ep 15 · 3:26
clinical In perineal fistula, the hole is too small and anterior to the center of the sphincters, causing the rectum and sigmoid to dilate as stool passes through a tiny fistulous orifice. ↗
▶ Ep 15 · 4:25
clinical The standard practice of checking temperature on the forehead or ear rather than rectally means the anus may not be examined, potentially missing malformations. ↗
▶ Ep 15 · 4:54
clinical Relocating a perineal fistula into the sphincters does not completely fix constipation, though it improves anatomy by making the hole adequately sized and lined by mucosa. ↗
▶ Ep 15 · 5:25
clinical Patients with uncorrected perineal fistula may have some continence with formed stool but will soil with loose stool or athletic activity because sphincter contraction cannot completely close the anteriorly located hole. ↗
▶ Ep 15 · 6:16
clinical A newborn anus should accept a size 12 Hagar dilator and a one-year-old should accept size 15. ↗
▶ Ep 15 · 6:42
clinical A bucket handle skin tag is consistent with perineal fistula; a probe can be passed underneath it even when the fistula itself is not visible. ↗
▶ Ep 15 · 7:33
opinion Diagnosing perineal fistula in females is probably the most confounding thing in pediatric colorectal surgery, with many patients either missed or overdiagnosed. ↗
▶ Ep 15 · 8:02
clinical Criteria for perineal fistula in females: hole too close to vagina (inadequate perineal body), inadequate hole size by Hagar dilators, and hole not centered in sphincter. ↗
▶ Ep 15 · 8:47
clinical If the hole is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, the patient does not need surgery; the perineal body will lengthen with growth. ↗
▶ Ep 15 · 9:08
quote It's very hard to improve on an asymptomatic patient. ↗
▶ Ep 15 · 9:51
clinical Examination under anesthesia with stimulation can confirm whether a questionable hole is properly centered within the sphincter. ↗
▶ Ep 15 · 11:06
clinical An anesthesia nerve stimulator costing $150 with appropriate needle probes works as well as commercial $15,000 sphincter stimulators. ↗
▶ Ep 15 · 11:06
quote You don't need to order those because you can take the anesthesia stimulator, which is $150 and then put these two nice little probes into the stimulator and connected to little needles and you get a beautiful sphincteric response. ↗
▶ Ep 15 · 12:18
clinical In rectourethral fistula, there is no anal opening and no hope for a hole; some babies pee meconium, making the diagnosis obvious. ↗
▶ Ep 15 · 12:45
clinical Rectourethral fistulas should not be approached primarily because the rectum location (bladder neck, prostatic, or bulbar level) is unknown; attempting posterior sagittal incision may find urinary tract structures instead of rectum. ↗
▶ Ep 15 · 13:20
clinical Rectourethral fistula patients should be managed with colostomy and distal colostogram, except in exceedingly rare cases where cross-table lateral at 20 hours shows very low rectum allowing safe primary posterior sagittal approach. ↗
▶ Ep 15 · 14:07
clinical Cloaca can be missed in the newborn period; a recent case presented at 6 months with constipation when someone finally noticed no anus. ↗
▶ Ep 15 · 15:54
clinical Ambiguous genitalia (clitoromegaly from endocrine stimulation) with urogenital sinus has a completely normal anus, distinguishing it from cloaca which has no anus. ↗
▶ Ep 15 · 16:24
clinical Cloaca patients have no endocrine problem and two completely normal ovaries, unlike urogenital sinus with virilization. ↗
▶ Ep 15 · 17:18
clinical The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through by the location of the colostomy or mucous fistula. ↗
▶ Ep 15 · 17:39
clinical Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections. ↗
▶ Ep 15 · 18:30
clinical Transverse colostomies can prolapse and, with large rectourethral fistula, the left colon absorbs urine causing acidosis; they also make distal colostogram difficult. ↗
▶ Ep 15 · 19:14
clinical Preferred technique is very proximal sigmoid colostomy leaving entire sigmoid for pull-through, with tiny flat mucous fistula separated from proximal stoma. ↗
▶ Ep 15 · 19:58
clinical Prolapse is related to colon mobility: mid-transverse colostomy both sides can prolapse, hepatic flexure only distal prolapses, proximal sigmoid only distal can prolapse because left colon is fixed to retroperitoneum. ↗
▶ Ep 15 · 20:37
clinical Ileostomies prolapse frequently because they are free-floating unless tacked to anterior abdominal wall. ↗
▶ Ep 15 · 21:30
clinical The anoplasty site should be marked before making the incision by drawing a circle around the pinkish ellipse where it stimulates on the skin surface, preventing confusion when anatomy is disrupted. ↗
▶ Ep 15 · 21:30
quote I actually make mark the anoplasty before I make the incision. I think you can get lost when you're looking at a bunch of jumping muscles from a stimulator. ↗
▶ Ep 15 · 22:04
clinical Without pre-marking, surgeons can choose the wrong place when seeing muscles jumping with stimulator after opening posterior sagittal incision, requiring re-operation despite good muscle potential. ↗
▶ Ep 15 · 23:04
quote Really, really good surgeons have put anuses in crazy places, and I think it's because they don't have a sense of what's the center because everything's disrupted once it's open. ↗
▶ Ep 15 · 23:29
clinical The distal colostogram is an absolutely vital study; many mistakes result from poorly done studies and misinterpretation. ↗
▶ Ep 15 · 23:55
clinical The colostogram must answer: where is the rectum, how low is it, is it reachable posterior sagittally or better laparoscopically, and what is its relationship to the urinary tract. ↗
▶ Ep 15 · 24:11
clinical Common colostogram error is insufficient contrast and pressure, giving false impression of high rectum and no fistula. ↗
▶ Ep 15 · 24:26
clinical If the distal rectum shows a straight line corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure; more pressure will show bulging rectum and fistula. ↗
▶ Ep 15 · 24:26
quote If you see that flattening of the rectum, you know the radiologist did not give enough of contrast, enough pressure, because you need to overcome the PC line because that's the sphincters. ↗
▶ Ep 15 · 25:23
quote I like to look at the urethra and think of it as a reverse C. Or let's say an elbow, and I think if the fistula is at the elbow or below, it's a bulbar fistula, and if the fistula is above the elbow, it's a prostatic fistula. ↗
▶ Ep 15 · 25:23
clinical Fistula classification using urethra as reverse C or elbow: fistula at or below elbow is bulbar, above elbow is prostatic, at bladder neck is bladder neck fistula. ↗
▶ Ep 15 · 25:55
clinical Bulbous rectum may be reachable posterior sagittally and hard laparoscopically due to girth; tapered rectum is better approached laparoscopically. ↗
▶ Ep 15 · 27:00
clinical Opening posterior sagittally without knowing rectum location will find a whitish shiny structure that may be bladder neck, not rectum. ↗
▶ Ep 15 · 28:42
clinical Adjunct techniques to locate rectum include balloon catheter in mucous fistula inflated with fluid or gastroscope to look for light, though the speaker has not used these. ↗
▶ Ep 15 · 29:28
quote You should never go to the operating room without knowing exactly what anatomy you're going to expect to find. ↗
▶ Ep 15 · 29:28
clinical Never go to the operating room without knowing exactly what anatomy to expect from a proper distal colostogram; the key question is where is the rectum and is it the most posterior structure. ↗
▶ Ep 15 · 30:09
clinical Bulbar or low prostatic rectum with bulge is more easily approached posterior sagittally; high prostatic tapered rectum is best served by laparoscopy; bladder neck fistulas are certainly best by laparoscopy. ↗
▶ Ep 15 · 30:43
clinical Laparoscopy for bulging rectum below peritoneal reflection at low prostatic or bulbar level requires unnecessary extra work and risks leaving remnant of original fistula (roof) if surgeon is timid. ↗
▶ Ep 15 · 31:16
clinical Posterior sagittal approach for high rectum is very difficult to mobilize and risks urinary tract injury. ↗
▶ Ep 15 · 31:48
quote I never look at it that way. I think that laparoscopy replaces laparotomy. It's an elegant dissection from above, but don't give away the advantages of the PSARP. ↗
▶ Ep 15 · 31:48
clinical Laparoscopy replaces laparotomy as elegant dissection from above but should not give away advantages of PSARP; a mini-PSARP during laparoscopy allows safe pelvic entry and rectal tacking to prevent prolapse. ↗
▶ Ep 15 · 32:44
quote I like to call mine a laparoscopic assisted PSARP. I think that's a better terminology. ↗
▶ Ep 15 · 32:44
opinion Preferred terminology is laparoscopic-assisted PSARP rather than laparoscopy versus PSARP. ↗
▶ Ep 15 · 33:04
clinical Prolapse prevention: proper levator closure, tacking rectum to posterior edge of muscle complex for 3-4 stitches, not dissecting rectum more than necessary, avoiding excessive trimming. ↗
▶ Ep 15 · 33:35
epidemiological Prolapse occurs in about 3% of cases, particularly in those without great muscles. ↗
▶ Ep 15 · 33:54
clinical Rectal prolapse causes bleeding, mucus, and can inhibit bowel control in patients with good muscle potential because they cannot close the opening with prolapsed tissue through it. ↗
▶ Ep 15 · 34:18
clinical Prolapse more than 3 millimeters should be treated; ideal time is when colostomy is still present. ↗
▶ Ep 15 · 34:48
clinical For circumferential prolapse, performing half the circumference in two different ambulatory settings is preferred by families over hospitalization and avoids need for dilation since half is untouched. ↗
▶ Ep 15 · 35:41
clinical Perineal body dehiscence prevention requires complete anterior rectal wall separation from posterior vaginal wall to reach areolar plane, avoiding tension on anoplasty. ↗
▶ Ep 15 · 36:03
clinical Perineal body dehiscence is the most common cause of reoperation in female ARM repairs. ↗
▶ Ep 15 · 36:35
clinical Traditional postoperative management is NPO for 7 days on 10% dextrose (hyperalimentation only if longer than 7 days); recently trialing clear liquids only for a week to avoid hard stool while allowing some oral intake. ↗
▶ Ep 15 · 37:32
clinical Daily perineal examination during the first week is critical; if dehiscence is detected on day 5-8, taking the patient back to OR to re-suture can salvage the repair, but by 3-4 weeks later nothing can be done. ↗
▶ Ep 15 · 37:48
quote If you see it's opening, I actually will take them back to the OR and re-suture the perineal body. You can actually save it by doing that. ↗
▶ Ep 15 · 38:36
clinical Laparoscopy causes trouble if dissecting a rectum that is too low, getting too close to urinary tract or being too timid and leaving remnant of original fistula (distal rectum). ↗
▶ Ep 15 · 39:20
clinical For high rectums, particularly bladder neck fistulas, dissection to make the rectum reach with good blood supply is challenging; the IMA must be preserved because prior colostomy may have disrupted left colic collaterals. ↗
▶ Ep 15 · 39:47
clinical The rectum has excellent intramural blood supply from the IMA; taking tiny distal vessels along the rectal wall preserves this, but taking IMA or branches too close to aorta will cause rectal necrosis. ↗
▶ Ep 15 · 40:18
clinical The biggest PSARP problem is exploring without knowing rectum location and finding bladder neck, urethra, seminal vesicles, vas deferens, or ectopic ureter instead of distal rectum. ↗
▶ Ep 15 · 41:02
quote There are some famous cases of pull through bladder neck made into beautiful anoplasties. And then post op, the patient was draining liquid out their anoplasty, and in fact it was the bladder neck. ↗
▶ Ep 15 · 41:02
clinical Famous cases exist of bladder neck being pulled through and made into beautiful anoplasties, with the patient postoperatively draining liquid (urine) from the anoplasty. ↗
▶ Ep 15 · 42:14
clinical To determine continence potential, assess three factors: original malformation type, sacral quality and calculated sacral ratio, and spine quality (ARM continence index). ↗
▶ Ep 15 · 42:57
clinical Three A's in continence index (malformation type, sacrum, spine) predicts continence; three C's predicts incontinence; intermediate grades are being quantified through data collection. ↗
▶ Ep 15 · 43:19
clinical Bulbar fistula with sacral ratio of 1 and normal spine should absolutely have bowel control; bladder neck fistula with sacral ratio 0.4 and tethered cord or myelomeningocele has no chance of good bowel control. ↗
▶ Ep 15 · 43:52
clinical For 4-year-old with soiling and continence potential, first step is mechanical cleaning with bowel management enemas to gain confidence, then when older try switching to laxatives for voluntary bowel movements. ↗
▶ Ep 15 · 44:25
clinical If patient cannot be weaned from enemas, consider antegrade option like Malone procedure. ↗
▶ Ep 15 · 44:39
clinical Indications for redo pull-through: any continence potential with imperfect anatomy including improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum). ↗
▶ Ep 15 · 45:08
clinical Redoing anoplasty to center rectum in sphincter can change a patient to have continence potential; success is very good when the right patient is selected. ↗
▶ Ep 15 · 46:25
quote I think one of the biggest problems with anorectal malformations is that if you don't get it right, you don't really know for a few years. Most things in surgery, if you don't do it right, you know right away. ↗
▶ Ep 15 · 46:25
opinion One of the biggest problems with anorectal malformations is that surgical errors do not become apparent for years, unlike most surgical complications which are evident immediately. ↗
▶ Ep 15 · 46:59
quote How are you supposed to as a surgeon, know what to fix about your technique if your problems are only becoming obvious years later? And I think that's why there is so much morbidity in colorectal. ↗

Posterior Sagittal Anorectaplasty in a Female: Pediatric Colorectal...

▶ Ep 27 · 1:17
quote This is a very good representation. I just have a very good question. I have a very good use. ↗
▶ Ep 27 · 1:17
quote This is a very good representation. I just have a very good question. I have a very good use. ↗
▶ Ep 27 · 3:21
clinical In babies this small, MRI has difficulty delineating uterine and ovarian structures ↗
▶ Ep 27 · 3:21
clinical In babies this small, MRI has difficulty delineating uterine and ovarian structures ↗
▶ Ep 27 · 7:47
clinical Train-of-four box from anesthesia machine is a less expensive alternative to dedicated nerve stimulator for muscle mapping ↗
▶ Ep 27 · 7:47
clinical Train-of-four box from anesthesia machine is a less expensive alternative to dedicated nerve stimulator for muscle mapping ↗
▶ Ep 27 · 9:59
quote I don't see a vagina. No, I don't see a vaginal opening at all. ↗
▶ Ep 27 · 9:59
quote I don't see a vagina. No, I don't see a vaginal opening at all. ↗
▶ Ep 27 · 15:16
quote Lateral defines the anterior. First step, lateral. I want a nice, clean lateral plane. ↗
▶ Ep 27 · 15:16
clinical Lateral dissection defines the anterior plane in rectal mobilization - first step is to establish clean lateral plane ↗
▶ Ep 27 · 15:16
quote Lateral defines the anterior. First step, lateral. I want a nice, clean lateral plane. ↗
▶ Ep 27 · 15:16
clinical Lateral dissection defines the anterior plane in rectal mobilization - first step is to establish clean lateral plane ↗
▶ Ep 27 · 19:47
clinical In absent vagina situations with recto-vestibular fistula, the urethra is characteristically enlarged ↗
▶ Ep 27 · 19:47
clinical In absent vagina situations with recto-vestibular fistula, the urethra is characteristically enlarged ↗
▶ Ep 27 · 20:28
clinical In this patient population, there is thick wall between rectum and urethra in absent vagina situations ↗
▶ Ep 27 · 20:28
clinical In this patient population, there is thick wall between rectum and urethra in absent vagina situations ↗
▶ Ep 27 · 27:20
opinion Surgeon would not perform independent examination under anesthesia in straightforward newborn primary anorectal malformation case, but would examine at time of repair ↗
▶ Ep 27 · 27:20
opinion Surgeon would not perform independent examination under anesthesia in straightforward newborn primary anorectal malformation case, but would examine at time of repair ↗
▶ Ep 27 · 35:07
clinical When fat is visible during rectal dissection, surgeon can safely dissect closer to the bowel wall ↗
▶ Ep 27 · 35:07
clinical When fat is visible during rectal dissection, surgeon can safely dissect closer to the bowel wall ↗
▶ Ep 27 · 48:12
quote I think technically it's the ideal time to do the neovagina when the rectum has been mobilized. I think that would be a mistake. I think it would be a very scarred perineum to then put a neovagina through. ↗
▶ Ep 27 · 48:12
quote I think technically it's the ideal time to do the neovagina when the rectum has been mobilized. I think that would be a mistake. I think it would be a very scarred perineum to then put a neovagina through. ↗
▶ Ep 27 · 48:12
opinion Best time to create neovagina is when rectum has been mobilized; waiting creates scarred perineum making later reconstruction more difficult ↗
▶ Ep 27 · 48:12
opinion Best time to create neovagina is when rectum has been mobilized; waiting creates scarred perineum making later reconstruction more difficult ↗
▶ Ep 27 · 49:17
opinion Staple lines should be removed from neovaginal segment rather than left in place ↗
▶ Ep 27 · 49:17
opinion Staple lines should be removed from neovaginal segment rather than left in place ↗
▶ Ep 27 · 59:42
opinion Surgeon prefers colon over small bowel for neovagina because small bowel mesentery is more tenuous and colon has more robust blood supply ↗
▶ Ep 27 · 59:42
opinion Surgeon prefers colon over small bowel for neovagina because small bowel mesentery is more tenuous and colon has more robust blood supply ↗
▶ Ep 27 · 1:05:08
clinical Standard neovaginal length in infant is 7-8 centimeters based on normal vaginal length in babies ↗
▶ Ep 27 · 1:05:08
clinical Standard neovaginal length in infant is 7-8 centimeters based on normal vaginal length in babies ↗
▶ Ep 27 · 1:07:53
quote I don't know what's going to happen with our technology and our ability to think with uteruses. I mean, who would have thought a year ago that there would be such a thing as a uterine transplantation? ↗
▶ Ep 27 · 1:07:53
quote I don't know what's going to happen with our technology and our ability to think with uteruses. I mean, who would have thought a year ago that there would be such a thing as a uterine transplantation? ↗
▶ Ep 27 · 1:08:53
clinical Neovagina should be tacked to pelvic fascia or posterior bladder to prevent prolapse and ensure it grows with the patient ↗
▶ Ep 27 · 1:08:53
clinical Neovagina should be tacked to pelvic fascia or posterior bladder to prevent prolapse and ensure it grows with the patient ↗
▶ Ep 27 · 1:09:37
clinical Six months after breast budding is appropriate timing for pelvic ultrasound and vaginoscopy to assess Müllerian structures and menstrual patency ↗
▶ Ep 27 · 1:09:37
opinion Surgeon does not dilate neovaginas post-operatively, anticipating some patients will need minor revision but avoiding torture of vaginal dilations ↗
▶ Ep 27 · 1:09:37
clinical Six months after breast budding is appropriate timing for pelvic ultrasound and vaginoscopy to assess Müllerian structures and menstrual patency ↗
▶ Ep 27 · 1:09:37
opinion Surgeon does not dilate neovaginas post-operatively, anticipating some patients will need minor revision but avoiding torture of vaginal dilations ↗
▶ Ep 27 · 1:09:37
quote I think it's a lot of torture to make them go through vasomal dilations. ↗
▶ Ep 27 · 1:09:37
quote I think it's a lot of torture to make them go through vasomal dilations. ↗
▶ Ep 27 · 1:22:15
host_summary MRI has limited ability to determine presence of vaginal lumen in very young patients unless there is clear hematocolpos or hydrocolpos ↗
▶ Ep 27 · 1:22:15
clinical MRI has limited ability to determine presence of vaginal lumen in very young patients unless there is clear hematocolpos or hydrocolpos ↗
▶ Ep 27 · 1:26:40
quote 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 PSAR. ↗
▶ Ep 27 · 1:26:40
quote 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 PSAR. ↗

Posterior Sagittal Anorectaplasty-Female Part III: Pediatric Colorectal...

▶ Ep 24 · 2:12
clinical Colon is preferred over small bowel for neovagina construction because small bowel mesentery is more tenuous and colon has more robust blood supply. ↗
▶ Ep 24 · 2:12
quote 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. ↗
▶ Ep 24 · 2:12
quote 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. ↗
▶ Ep 24 · 2:12
clinical Colon is preferred over small bowel for neovagina construction because small bowel mesentery is more tenuous and colon has more robust blood supply. ↗
▶ Ep 24 · 7:56
clinical 7-8 centimeters is used for neovaginal conduit length based on normal vaginal length in an infant, though there is no science behind this measurement. ↗
▶ Ep 24 · 7:56
clinical 7-8 centimeters is used for neovaginal conduit length based on normal vaginal length in an infant, though there is no science behind this measurement. ↗
▶ Ep 24 · 7:56
quote I just normally in a baby do about 78 centimeters because that's what a normal vaginal length looks like in a. I think there's no science behind that at all. ↗
▶ Ep 24 · 7:56
quote I just normally in a baby do about 78 centimeters because that's what a normal vaginal length looks like in a. I think there's no science behind that at all. ↗
▶ Ep 24 · 10:09
clinical The family agreed to preserve structures that did not need removal, acknowledging uncertainty about future technology and outcomes. ↗
▶ Ep 24 · 10:09
clinical The family agreed to preserve structures that did not need removal, acknowledging uncertainty about future technology and outcomes. ↗
▶ Ep 24 · 10:27
quote I mean, who would have thought a year ago that there would be such a thing as a uterine transplantation. The successful. ↗
▶ Ep 24 · 10:27
quote I mean, who would have thought a year ago that there would be such a thing as a uterine transplantation. The successful. ↗
▶ Ep 24 · 10:27
clinical Uterine transplantation has become successful within the past year, representing advancement in reproductive technology. ↗
▶ Ep 24 · 10:27
clinical Uterine transplantation has become successful within the past year, representing advancement in reproductive technology. ↗
▶ Ep 24 · 11:10
clinical Neovagina should be tacked to pelvic fascia or posterior bladder to prevent prolapse and allow it to grow and lengthen into the pelvis. ↗
▶ Ep 24 · 11:10
clinical Neovagina should be tacked to pelvic fascia or posterior bladder to prevent prolapse and allow it to grow and lengthen into the pelvis. ↗
▶ Ep 24 · 11:58
clinical Vaginal dilation is not performed post-operatively; a certain percentage will need introitoplasty later, but dilation is considered torture for patients. ↗
▶ Ep 24 · 11:58
clinical Vaginal dilation is not performed post-operatively; a certain percentage will need introitoplasty later, but dilation is considered torture for patients. ↗
▶ Ep 24 · 11:58
quote 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. ↗
▶ Ep 24 · 11:58
quote 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. ↗
▶ Ep 24 · 12:13
clinical Six months after breast budding, Müllerian structures must be monitored for dilation and menstrual function assessed. ↗
▶ Ep 24 · 12:13
clinical Six months after breast budding, Müllerian structures must be monitored for dilation and menstrual function assessed. ↗
▶ Ep 24 · 12:29
clinical Vaginoscopy should be performed after breast budding to determine if a cervix is present and if structures are larger. ↗
▶ Ep 24 · 12:29
clinical Vaginoscopy should be performed after breast budding to determine if a cervix is present and if structures are larger. ↗
▶ Ep 24 · 13:55
clinical If no cervix is found on vaginoscopy, there is a difficult decision between empirical removal of Müllerian structures or waiting for complications. ↗
▶ Ep 24 · 13:55
clinical If no cervix is found on vaginoscopy, there is a difficult decision between empirical removal of Müllerian structures or waiting for complications. ↗
▶ Ep 24 · 14:17
clinical In patients without a cervix, some develop pelvic inflammatory disease episodes requiring removal, while others remain asymptomatic. ↗
▶ Ep 24 · 14:17
clinical In patients without a cervix, some develop pelvic inflammatory disease episodes requiring removal, while others remain asymptomatic. ↗
▶ Ep 24 · 19:58
clinical Anal transitional epithelium (dentate line) should be preserved during anoplasty rather than excised. ↗
▶ Ep 24 · 19:58
clinical Anal transitional epithelium (dentate line) should be preserved during anoplasty rather than excised. ↗
▶ Ep 24 · 24:51
clinical Pelvic MRI in infants struggles to identify vaginal lumen unless there is clearly hematocolpos or hydrocolpos; it is less helpful than desired. ↗
▶ Ep 24 · 24:51
clinical Pelvic MRI in infants struggles to identify vaginal lumen unless there is clearly hematocolpos or hydrocolpos; it is less helpful than desired. ↗
▶ Ep 24 · 25:20
quote It's always promises to be much better than it is, and. The very young patient ↗
▶ Ep 24 · 25:20
quote It's always promises to be much better than it is, and. The very young patient ↗
▶ Ep 24 · 25:32
clinical MRI can frequently identify fallopian tubes, ovaries, and uterine anatomy, but determining the presence and characteristics of the vaginal lumen is very challenging with low confidence. ↗
▶ Ep 24 · 25:32
clinical MRI can frequently identify fallopian tubes, ovaries, and uterine anatomy, but determining the presence and characteristics of the vaginal lumen is very challenging with low confidence. ↗
▶ Ep 24 · 26:14
clinical Keeping fluid in the vagina during MRI imaging is difficult once the patient is in the magnet. ↗
▶ Ep 24 · 26:14
clinical Keeping fluid in the vagina during MRI imaging is difficult once the patient is in the magnet. ↗
▶ Ep 24 · 27:31
opinion No preoperative workup including independent examination under anesthesia, MRI, or better scoping would have changed the surgical approach in this case. ↗
▶ Ep 24 · 27:31
quote 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. ↗
▶ Ep 24 · 27:31
opinion No preoperative workup including independent examination under anesthesia, MRI, or better scoping would have changed the surgical approach in this case. ↗
▶ Ep 24 · 27:31
quote 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. ↗
▶ Ep 24 · 28:15
quote None of the imaging hinted at this, and even the office exam looked amazingly normal from a, a gynecologic point of view. ↗
▶ Ep 24 · 28:15
clinical None of the imaging or office examination hinted at the Müllerian anatomy found intraoperatively; the office exam looked amazingly normal from a gynecologic point of view. ↗
▶ Ep 24 · 28:15
clinical None of the imaging or office examination hinted at the Müllerian anatomy found intraoperatively; the office exam looked amazingly normal from a gynecologic point of view. ↗
▶ Ep 24 · 28:15
quote None of the imaging hinted at this, and even the office exam looked amazingly normal from a, a gynecologic point of view. ↗
▶ Ep 24 · 29:20
clinical When the neovagina is connected to the patient's native vagina, it is already tethered into the abdomen and does not require additional tacking to the bladder. ↗
▶ Ep 24 · 29:20
clinical When the neovagina is connected to the patient's native vagina, it is already tethered into the abdomen and does not require additional tacking to the bladder. ↗

ARMs in Female Patients: Pediatric Colorectal Controversies 2014

▶ Ep 29 · 0:23
clinical Perineal fistula is diagnosed when the fistula opening is at or anterior to the fourchette, with normal urethra and vagina visible ↗
▶ Ep 29 · 1:53
clinical Vestibular fistula is diagnosed when the fistula opens posterior to the fourchette within the vestibule ↗
▶ Ep 29 · 2:50
quote I'd like to have it completely separated from the vagina because you'll find there's a... It's always very attached to it. It's like the common wall. If you finally get it loose, you can place the tension free. ↗
▶ Ep 29 · 2:50
opinion Complete separation from vagina is preferred because incomplete mobilization may lead to retraction and wound problems ↗
▶ Ep 29 · 5:40
quote 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. ↗
▶ Ep 29 · 5:40
clinical In every redo of a female ARM, areolar tissue is found that had never been dissected by the original surgeon ↗
▶ Ep 29 · 6:10
clinical Inadequate anterior rectal wall mobilization can lead to perineal body disruption as the anterior wall pulls back ↗
▶ Ep 29 · 13:09
clinical The rectal blood supply is intramural, so injuring the rectal wall hurts its blood supply ↗
▶ Ep 29 · 13:35
clinical Starting laterally before attempting anterior separation is key to avoiding injury when separating rectum from vagina ↗
▶ Ep 29 · 15:00
opinion Primary vestibular repair without colostomy can be done in newborn or within 3-4 months depending on child's condition ↗
▶ Ep 29 · 16:28
opinion Waiting until perineal body is healed (day 6-7) before feeding allows intervention if dehiscence is developing ↗
▶ Ep 29 · 17:18
clinical 10% dextrose can be used for NPO periods up to 7 days in well-nourished children, avoiding need for hyperalimentation ↗
▶ Ep 29 · 18:48
epidemiological Systematic review shows early enteral nutrition appears better than later nutrition in ARM patients, but all studies are retrospective and poor quality ↗
▶ Ep 29 · 20:53
quote The plural of anecdote is not data. ↗
▶ Ep 29 · 26:39
epidemiological About 2-5% of vestibular fistulas have a vaginal septum ↗
▶ Ep 29 · 26:58
opinion The ideal time to remove a vaginal septum is when the rectum is being mobilized and the perineal body is open ↗
▶ Ep 29 · 29:17
clinical Women with longitudinal vaginal septum often learn to work around it for intercourse but have problems with tampon use ↗
▶ Ep 29 · 30:30
clinical Vaginal septum resection in adolescents is not a difficult operation and can be done with electrocautery ↗
▶ Ep 29 · 32:28
clinical True vaginal fistula (within introitus) is rare and requires slightly more rectal mobilization than vestibular fistula ↗
▶ Ep 29 · 35:33
opinion Using rectum as vagina and mobilizing proximal bowel as neo-rectum should only be done if patient unlikely to be continent (spinal anomaly, absent sacrum) ↗
▶ Ep 29 · 37:18
clinical Rectum separates from urethra more easily than from vagina in absent vagina cases, with thick fibrous tissue rather than adherent common wall ↗
▶ Ep 29 · 38:42
clinical Neovagina is technically easier in younger children because the pedicle reaches more easily in a shorter pelvis ↗
▶ Ep 29 · 44:12
clinical There are two types of cloacas: lower ones (common channel ≤3 cm) and complicated ones (>3 cm) ↗
▶ Ep 29 · 44:40
clinical Hydrocolpos in cloaca may obstruct distal ureters and cause bilateral hydronephrosis ↗
▶ Ep 29 · 44:51
epidemiological About 50% of cloacas have a duplicated gynecologic system ↗
▶ Ep 29 · 45:10
opinion For newborn cloaca with hydrocolpos, open divided colostomy with pigtail catheter decompression of vagina is preferred over formal vaginostomy ↗
▶ Ep 29 · 45:49
clinical Attempting cystoscopy at time of colostomy creation in cloaca makes the colostomy very difficult ↗
▶ Ep 29 · 47:53
clinical Laparoscopic approach for cloaca colostomy allows visualization of pelvic structures and percutaneous vaginostomy tube placement ↗
▶ Ep 29 · 48:50
clinical Curled tube is preferred over straight tube for vaginostomy because straight tubes fall out at 2 months when inflammation resolves ↗
▶ Ep 29 · 50:11
clinical Intermittent catheterization of cloaca 2-3 times daily can drain urine and avoid need for vaginostomy tube in many cases ↗
▶ Ep 29 · 51:00
clinical Catheterization teaching should be done under ultrasound guidance because tube can go into right vagina, left vagina, bladder, or rectum ↗
▶ Ep 29 · 52:45
clinical Once hydrocolpos is drained, the bladder can fill, demonstrating that hydrocolpos compresses ureters and prevents bladder filling ↗

Complications of Anorectal Malformations with Dr. Marc Levitt

▶ Ep 33 · 2:57
clinical Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period. ↗
▶ Ep 33 · 3:06
clinical Male babies with perineal fistula may pass meconium and no one notices anything wrong with their anorectal anatomy, typically presenting in the first year of life with severe constipation. ↗
▶ Ep 33 · 4:25
opinion The standard practice of checking temperature on forehead or ear rather than rectally makes it easier to miss anorectal malformations in newborns. ↗
▶ Ep 33 · 4:54
clinical Relocating a perineal fistula into the sphincters improves anatomy but does not completely fix constipation; patients will inherently have some constipation requiring aggressive treatment. ↗
▶ Ep 33 · 5:38
clinical If a perineal fistula is not centered in the sphincter, patients with loose stool will soil, and athletic activity will cause soiling because sphincter squeeze cannot completely close the hole. ↗
▶ Ep 33 · 6:13
clinical A newborn anus should accept a size 12 Hagar dilator and a 1-year-old should accept a size 15. ↗
▶ Ep 33 · 8:02
clinical In females, diagnostic criteria for perineal fistula are: hole too close to vagina (inadequate perineal body), inadequate hole size by Hagar dilators, and hole not centered in sphincter. ↗
▶ Ep 33 · 8:47
clinical If a female's anal opening is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, no surgery is needed; the perineal body will lengthen with growth. ↗
▶ Ep 33 · 9:08
quote It's very hard to improve on an asymptomatic patient. ↗
▶ Ep 33 · 11:06
quote You don't need to order those because you can take the anesthesia stimulator, which is $150 and then put these two nice little probes into the stimulator and connected to little needles and you get a beautiful sphincteric response. ↗
▶ Ep 33 · 11:06
clinical An anesthesia nerve stimulator costing $150 with appropriate needle probes works as well as commercial $15,000 stimulators for identifying sphincter muscles. ↗
▶ Ep 33 · 17:00
quote I think that operation of a colostomy needs to be taken very seriously, and every pediatric surgeon who deals with newborns, which is the art of our specialty, needs to be really, really good at this because there's a lot of morbidity that's conveyed to a patient with an improperly done colostomy. ↗
▶ Ep 33 · 17:18
clinical The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through by the location of the colostomy or mucous fistula. ↗
▶ Ep 33 · 17:45
clinical Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections. ↗
▶ Ep 33 · 18:38
clinical With transverse colostomy and large rectourethral fistula, the left colon absorbs urine which doesn't exit the mucous fistula, potentially causing acidosis from urine absorption. ↗
▶ Ep 33 · 19:58
clinical Prolapse risk depends on colostomy location: mid-transverse allows bilateral prolapse, hepatic flexure allows only distal prolapse, proximal sigmoid allows only distal prolapse because left colon is fixed to retroperitoneum. ↗
▶ Ep 33 · 21:30
quote I actually make mark the anoplasty before I make the incision. I think you can get lost when you're looking at a bunch of jumping muscles from a stimulator. ↗
▶ Ep 33 · 21:30
clinical Marking the sphincter ellipse on skin surface before making any incision prevents confusion from muscle stimulation after dissection is open, avoiding misplaced anoplasty. ↗
▶ Ep 33 · 24:26
quote If you see that flattening of the rectum, you know the radiologist did not give enough of contrast, enough pressure, because you need to overcome the PC line because that's the sphincters, that's where the sphincters are compressing the distal rectum. ↗
▶ Ep 33 · 24:26
clinical A distal colostogram showing flattening of the rectum corresponding to the pubococcygeal line indicates insufficient contrast or pressure; more pressure is needed to overcome the sphincters and reveal the true rectal position and fistula. ↗
▶ Ep 33 · 25:23
clinical Fistula level is determined by viewing the urethra as a reverse C or elbow: fistula at or below the elbow is bulbar, above the elbow is prostatic, at bladder neck is bladder neck fistula. ↗
▶ Ep 33 · 25:55
clinical Bulbous rectum on colostogram may be reachable posterior sagittally and difficult laparoscopically; tapered rectum is better approached laparoscopically. ↗
▶ Ep 33 · 27:00
clinical Opening posterior sagittally without knowing exact rectal location risks finding and potentially mobilizing bladder neck instead of rectum. ↗
▶ Ep 33 · 29:28
quote You should never go to the operating room without knowing exactly what anatomy you're going to expect to find. ↗
▶ Ep 33 · 30:09
clinical Bulbar and low prostatic fistulas with bulbous rectum are best approached posterior sagittally; high prostatic with tapered rectum and bladder neck fistulas are best approached laparoscopically. ↗
▶ Ep 33 · 30:43
clinical Attempting laparoscopy for bulging rectum below peritoneal reflection at low prostatic or bulbar level risks leaving behind a remnant of the original fistula (roof) if the surgeon is timid. ↗
▶ Ep 33 · 31:48
quote I think that laparoscopy replaces laparotomy. It's an elegant dissection from above, but don't give away the advantages of the PSARP. ↗
▶ Ep 33 · 31:48
opinion Laparoscopy replaces laparotomy, not PSARP; a mini-PSARP during laparoscopy allows safe entry through peritoneal reflection and tacking rectum to posterior muscle complex to prevent prolapse. ↗
▶ Ep 33 · 33:35
epidemiological Rectal prolapse occurs in about 3% of cases, particularly in patients without great muscles. ↗
▶ Ep 33 · 34:14
clinical Rectal prolapse more than 3 millimeters should be treated because it causes bleeding, mucus, and can inhibit bowel control in patients with good muscle potential. ↗
▶ Ep 33 · 34:48
clinical Circumferential prolapse can be trimmed in two separate ambulatory sessions (half circumference each), avoiding hospitalization and eliminating need for dilation since half the circumference remains untouched. ↗
▶ Ep 33 · 35:41
clinical Complete anterior rectal wall mobilization to the areolar plane between rectum and vagina is essential to avoid tension on the anoplasty that can lead to perineal body dehiscence. ↗
▶ Ep 33 · 36:03
clinical Perineal body dehiscence is the most common cause of reoperation in female ARM repairs. ↗
▶ Ep 33 · 36:45
clinical Clear liquids only for one week postoperatively prevents hard stool formation while allowing more stool volume, showing good perineal body healing results without traditional 7-day NPO period. ↗
▶ Ep 33 · 37:48
clinical If perineal body dehiscence is recognized on days 5-8, taking the patient back to OR to re-suture can salvage the repair; by 3-4 weeks the entire perineal body is dehisced and unsalvageable. ↗
▶ Ep 33 · 39:33
clinical During laparoscopic approach for high rectums, the IMA must be preserved because prior colostomy may have disrupted collaterals down the left colic, making the rectum completely dependent on IMA blood supply. ↗
▶ Ep 33 · 42:14
clinical Continence potential in ARM patients is predicted by three factors: original malformation type, sacral ratio, and spine quality (ARM continence index). Three A's predicts continence, three C's predicts incontinence. ↗
▶ Ep 33 · 43:19
clinical A bulbar fistula with sacral ratio of 1 and normal spine should have bowel control; a bladder neck fistula with sacral ratio of 0.4 and tethered cord or myelomeningocele has no chance of good bowel control. ↗
▶ Ep 33 · 43:52
clinical Initial management of soiling 4-year-old with continence potential is bowel management with enemas to achieve cleanliness, then trial of laxatives when older and more mature to attempt voluntary bowel movements. ↗
▶ Ep 33 · 44:39
clinical Indications for redo pull-through include any patient with continence potential who has improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum). ↗
▶ Ep 33 · 46:25
opinion The major problem with anorectal malformations is that surgical errors may not become apparent for years; an improperly placed anus appears successful initially but presents with soiling at age 4. ↗
▶ Ep 33 · 46:25
quote If you don't do it right, you don't really know for a few years. Most things in surgery, if you don't do it right, you know right away. ↗
▶ Ep 33 · 46:59
quote How are you supposed to as a surgeon, know what to fix about your technique if your problems are only becoming obvious years later? And I think that's why there is so much morbidity in colorectal. ↗

The Colorectal Quiz Episode 1: ARM - Low Bulbar Fistula

▶ Ep 34 · 3:01
guideline Anorectal malformation patients require screening for VACTERL association: vertebral abnormalities (plain X-ray), cardiac defects (exam and echo), esophageal atresia (NG tube pass), renal abnormalities (kidney ultrasound), and limb abnormalities (physical exam). ↗
▶ Ep 34 · 3:34
quote We want to make sure we've checked for any cardiac defect, both on exam and on echo. ↗
▶ Ep 34 · 3:55
clinical Sacral ratio measurement should wait until the child is 3 months of age for true measurements, though early imaging gives a feel for pelvic development. ↗
▶ Ep 34 · 4:22
clinical Spinal ultrasound in anorectal malformation patients should include evaluation of the presacral space to screen for presacral masses. ↗
▶ Ep 34 · 4:33
epidemiological Presacral masses are rare in typical imperforate anus but occur in almost half of anal stenosis or rectal atresia cases, which require MRI evaluation. ↗
▶ Ep 34 · 7:11
quote The sacrum looks quite normal. I bet this kid is gonna have a pretty normal sacral ratio, certainly greater than 0.7. Which connotes a very good prognosis for bowel control and really peace of mind for the family. ↗
▶ Ep 34 · 7:20
clinical A sacral ratio greater than 0.7 connotes very good prognosis for bowel control and provides peace of mind for families regarding potty training and school readiness at 4 years of age. ↗
▶ Ep 34 · 7:31
quote They want to know what's going to happen to this baby in 4 years when they need to potty train and go to school. ↗
▶ Ep 34 · 9:06
quote I think the key to deciding whether to dive into a perineum and posterior sagittal is, where is the rectum? ↗
▶ Ep 34 · 9:06
clinical The key to deciding whether to perform primary posterior sagittal anorectoplasty is knowing where the rectum is located; the danger is finding midline white structures like urethra, bladder neck, or bladder instead of rectum. ↗
▶ Ep 34 · 9:25
quote The danger is that you go in posterior sagittal, you don't know where the rectum is, and you find something midline and white, like the urethra, the bladder neck or the bladder itself. ↗
▶ Ep 34 · 9:42
clinical Colostomies and distal colostograms are performed to know exactly where the rectum is and whether to approach it perineally or laparoscopically. ↗
▶ Ep 34 · 10:18
quote I will tell you that the surgeon who sent me this case, they did not do that. They felt more comfortable doing a colostomy, and I wanna tell you, that was the safe thing to do. Bravo to them. That was the right choice. ↗
▶ Ep 34 · 10:24
clinical Colostomy is the safe choice for anorectal malformation repair, though it carries risks of complications from both the colostomy creation and the subsequent closure. ↗
▶ Ep 34 · 10:34
quote We are giving the child a colostomy. And whatever complications can happen from that, and we are giving the child a colostomy closure, and whatever complications can happen from that. ↗
▶ Ep 34 · 11:10
clinical Surgeons have performed primary anorectoplasty on low anorectal malformations without knowing about a fistula, resulting in children later urinating out of the anus. ↗
▶ Ep 34 · 11:10
quote This is sort of scary, because if you went in and grabbed this rectum and did a primary anoplasty. And did not know there was a fistula, and unfortunately, I have seen this done by some very good surgeons where they went in, did a beautiful anoplasty, but ignored the fistula, and the child down the road started peeing out their anus. ↗
▶ Ep 34 · 12:09
quote When I do that, I open up the posterior wall of the rectum and I inspect the anterior wall of the rectum. ↗
▶ Ep 34 · 12:09
clinical During primary posterior sagittal anorectoplasty, the surgeon should open the posterior wall of the rectum and inspect the anterior wall to rule out a fistula. ↗
▶ Ep 34 · 13:44
epidemiological 95% of Down syndrome patients with imperforate anus have no fistula, but 5% do have a fistula, so distal colostogram is still indicated. ↗
▶ Ep 34 · 13:48
quote 95% of Down's patients have no fistula, but 5% do. So I would still do a distal colostogram, and some of them might have a fistula. ↗

Colorectal Quiz Episode 2: When to redo a PSARP

▶ Ep 35 · 4:30
clinical The original malformation in Case 1 was a prostatic fistula. ↗
▶ Ep 35 · 4:40
clinical The patient in Case 1 has a tethered cord and a sacral ratio of 0.66. ↗
▶ Ep 35 · 7:29
clinical Visual cues for identifying correct sphincter location include the anal dimple, a midline raised area where the sphincters are, the ellipse, color change, indentation or raised area, and appropriate perineal body length. ↗
▶ Ep 35 · 8:40
clinical Case 2 patient was born with a vestibular fistula, has a normal spine and an excellent sacrum, indicating a much better prognosis for bowel control. ↗
▶ Ep 35 · 9:50
quote I get asked all the time about the stimulator. It's the same electrical stimulator that anesthesia uses for their train of four. And then there's a connection that you can make that has little pins. Really, really inexpensive. And you just have to tell your anesthesiologist not to give skeletal muscle relaxant because it's a little bit weaker than the traditional stimulator, which was super expensive. ↗
▶ Ep 35 · 9:50
clinical The electrical stimulator used is the same one that anesthesia uses for their train of four, with an inexpensive connection with little pins. ↗
▶ Ep 35 · 10:10
clinical You have to tell your anesthesiologist not to give skeletal muscle relaxant because the stimulator is a little bit weaker than the traditional stimulator. ↗
▶ Ep 35 · 12:00
host_summary The vast majority of patients who get redos had mislocation, followed by stricture, then less common reasons including remnant of the original fistula (roof), rectal prolapse, and others. ↗
▶ Ep 35 · 12:30
host_summary Quality of life improved with a redo operation. ↗
▶ Ep 35 · 12:40
host_summary Patients had an improved ability to achieve continence after redo operations. ↗
▶ Ep 35 · 12:50
host_summary Patients who did not develop voluntary bowel movements after redo were still able to be clean with a bowel management program using enemas or antegrade via a Malone. ↗
▶ Ep 35 · 12:55
host_summary In the JPS study, 20% of patients with a poor sacrum or poor spine actually developed bowel control after their redo. ↗
▶ Ep 35 · 13:10
host_summary The average age of patients in the JPS study is about three and a half years, give or take. ↗
▶ Ep 35 · 13:10
host_summary Patients with good potential (good sacrum and good spine) did extremely well after redo operations. ↗
▶ Ep 35 · 13:28
opinion If you know the anatomy is off, you should do the redo, and there's an advantage to getting the anatomy right the younger the child is. ↗
▶ Ep 35 · 13:50
opinion For a two-year-old with a mislocated anus or bad prolapse, offer a redo and let them live in diapers for a year or two with better anatomy, then see if they can successfully potty train. ↗
▶ Ep 35 · 14:20
clinical Many patients present after the age of potty training because they're incontinent, and evaluation reveals the reason is they don't have the best operation—their anus isn't in the right place. ↗
▶ Ep 35 · 14:30
opinion For patients presenting with incontinence after potty training age, do the redo and usually add a Malone at the same time so they can learn how to get control with their new anatomy before attempting voluntary bowel movements. ↗
▶ Ep 35 · 14:35
clinical The process of learning control with new anatomy after redo and Malone may take 6 to 12 months. ↗
▶ Ep 35 · 15:03
opinion For a patient with a mislocated anus that's 50% within the sphincter complex, three and a half years old and fecally incontinent, one approach is to redo them, do a Malone, get them perfectly clean mechanically, then see if they can develop bowel control. ↗
▶ Ep 35 · 15:45
opinion If patients haven't declared their continence yet because they're not old enough to do so from a behavioral point of view, give them a chance—they may succeed. ↗

Colorectal Quiz Episode 13: Newborn ARM Part 2

▶ Ep 38 · 2:34
clinical Indications for surgery in female ARM include: hole too small, hole not in center of sphincter, and inadequate perineal body ↗
▶ Ep 38 · 2:34
quote You must achieve a hole in the center of the sphincter with an adequate peroneal body. And those are the indications for surgery. ↗
▶ Ep 38 · 7:14
clinical If anal opening is adequately sized, surrounded by sphincter, and has a perineal body (albeit short), no surgery is indicated ↗
▶ Ep 38 · 8:01
clinical Short perineal body will grow over time and there is nothing to do about it surgically ↗
▶ Ep 38 · 8:01
quote One of our professors like to say, and we trained at the same place, Jason and I, the great Mount Sinai in New York, it's very hard to improve on an asymptomatic patient. ↗
▶ Ep 38 · 8:39
quote I think that if you don't have a sphincter on the anterior aspect of the analplasty, they will leak stool because they won't be able to close the hole. ↗
▶ Ep 38 · 8:39
clinical If half the fistula is within sphincter complex and half outside, patient will leak stool because they cannot close the hole, making surgery worthy ↗
▶ Ep 38 · 11:25
clinical Cloaca patients do not need endocrine workup or steroids and there is no question of gender assignment - they are female ↗
▶ Ep 38 · 11:25
clinical Cloaca patients are still being misdiagnosed as ambiguous genitalia, with some babies not having proper gender assignment for one to two weeks ↗
▶ Ep 38 · 11:25
clinical Cloaca presents with single perineal orifice and hypertrophied area around clitoral hood is typical, not ambiguous genitalia ↗
▶ Ep 38 · 11:25
quote This patient has no endocrine problem, does not need steroids, does not need an endocrinologic workup. This is a cloaca. There's no question of their gender assignment. It's a female. ↗
▶ Ep 38 · 11:25
quote That little hypertrophied area around the clitoral hood on the right photo is fairly typical, and it is not, and I repeat, not ambiguous genitalia. ↗
▶ Ep 38 · 13:26
quote You really want to push down and flatten the perineal body. That is the key. You want to see if the perineal body is normal or not. ↗
▶ Ep 38 · 13:26
clinical Key to perineal exam is to push down and flatten the perineal body to assess if it is normal ↗
▶ Ep 38 · 13:47
clinical Normal anus is centered within sphincter, of adequate size, and perineal body is of normal length properly distanced from vestibule ↗

The Colorectal Quiz Episode 23: Hirschsprung Disease - The Soiling Patient...

▶ Ep 41 · 1:17
quote Let's talk dentate line, shall we? ↗
▶ Ep 41 · 1:23
clinical The three components of continence are quality of sphincters, quality of dentate line, and motility. ↗
▶ Ep 41 · 1:23
quote Remember, the three components of continence are quality of sphincters, quality of dentate line, and motility. ↗
▶ Ep 41 · 1:30
clinical In Hirschsprung disease, two sphincters are of concern: the external sphincter (under voluntary control) and the internal sphincter (which tends not to relax due to absent rectoanal inhibitory reflex). ↗
▶ Ep 41 · 1:45
clinical If both internal and external sphincters have been overstretched, both become problematic. ↗
▶ Ep 41 · 1:57
clinical A patient who has voluntary bowel movements during the day but soils at night indicates working external sphincters but non-functioning internal sphincters; when sleeping, they relax the external sphincter and lose control. ↗
▶ Ep 41 · 1:57
quote One very typical scenario that we see, let me ask you, what do you think it means if you have a patient that has voluntary bowel movements during the day and has accidents when they go to sleep. ↗
▶ Ep 41 · 2:08
quote So at night, they poop, but during the day, they have control. What does that mean to you here? What, what is working and what is not working? ↗
▶ Ep 41 · 2:35
clinical Loss of dentate line can occur with overstretching and some preservation of external sphincter, resulting in daytime control but nighttime soiling. ↗
▶ Ep 41 · 4:53
quote I'm, I'm, I'm gonna sign off and you guys just, ↗
▶ Ep 41 · 4:58
clinical The rectum (not the anal canal) has proprioception capacity to detect stretch, which is the signal that stool is accumulating and it's time to hold stool and find a bathroom. ↗
▶ Ep 41 · 4:58
quote I actually, if I may add one more thing, I also think that there is a proprioception concept, the stretch. ↗
▶ Ep 41 · 5:07
clinical In anorectal malformation patients, the rectum should be preserved because rectal stretch provides proprioception. ↗
▶ Ep 41 · 5:22
quote That's called proprioception, and that's your signal. Uh oh, stool is accumulating. It's time to exert some authority over my external sphincter, hold the stool in and find a bathroom. ↗
▶ Ep 41 · 5:36
clinical When the internal sphincter is functioning properly, it relaxes at the time of rectal stretch. ↗
▶ Ep 41 · 5:43
quote This is why in ARM patients, in erectal malformation patients, giving them a stool softener is so problematic, because basically, they never feel the stretch. They just have loose stool flowing. ↗
▶ Ep 41 · 5:43
clinical Giving anorectal malformation patients stool softeners is problematic because they never feel the stretch; loose stool just flows and they will never have control of that. ↗
▶ Ep 41 · 5:58
quote So they are much better off with bulk, which is then kicked out by a laxative, than a stool softener that just slowly oozes out, they'll never have control of that. ↗
▶ Ep 41 · 5:58
clinical ARM patients are much better off with bulk (kicked out by a laxative) than a stool softener that slowly oozes out. ↗
▶ Ep 41 · 7:41
quote And they said, well, I'm not yet farting with confidence. ↗
▶ Ep 41 · 7:47
quote And what that says is so important because loose stool. Is your enemy if you have borderline continence. It's your enemy if you have completely normal continents. Right? Loose stool is hard to deal with, because you don't know for sure that it's there. ↗
▶ Ep 41 · 7:47
clinical Loose stool is the enemy if you have borderline continence or even completely normal continence, because you don't know for sure that it's there. ↗
▶ Ep 41 · 8:07
quote We are very dependent on the stretch, on the bulk of the stool in the rectum, and then that's when the external sphincter goes into motion, and the internal sphincter relaxes. ↗
▶ Ep 41 · 8:07
clinical We are very dependent on the stretch and bulk of stool in the rectum; that's when the external sphincter goes into motion and the internal sphincter relaxes. ↗
▶ Ep 41 · 8:19
clinical Hirschsprung patients with absolutely intact sphincters are dependent on that stretch; they don't have a rectum (it's been removed) and their sigmoid has taken over that job. ↗
▶ Ep 41 · 8:19
quote Patients with Hirschprung's disease, with absolutely intact sphincters. Are dependent on that stretch, remember, they don't have a rectum, it's been removed. Their sigmoid has now taken over that job. ↗
▶ Ep 41 · 8:32
quote If they have injured sphincters, they're particularly in trouble. ↗
▶ Ep 41 · 8:32
clinical Hirschsprung patients with injured sphincters are particularly in trouble regarding dependence on stool bulk and stretch. ↗
▶ Ep 41 · 9:00
quote This is a trick question because this patient's never had any surgery. This patient is about to get a biopsy to rule out Hirschrung's disease, and I took this picture of a absolutely totally normal, never touched dentate line. ↗
▶ Ep 41 · 10:44
clinical A patient with missing dentate line can develop bowel control provided their sphincters are working, but they will be very sensitive to loose stool. ↗
▶ Ep 41 · 10:44
quote I do think it's a myth to say that this patient cannot have bowel control. I think this patient can develop bowel control, provided their sphincters are working. ↗
▶ Ep 41 · 10:55
quote They will be very sensitive to loose stool. They won't be good at detecting that something is there unless they have bulk, but if they have the right diet and the right stool consistency, And sphincters that are intact, we can get this patient through, but it's really challenging if they have a missing dentate. ↗
▶ Ep 41 · 11:00
clinical Patients with missing dentate line won't be good at detecting that something is there unless they have bulk, but with the right diet, right stool consistency, and intact sphincters, they can achieve control. ↗
▶ Ep 41 · 11:38
quote So here you're about to go train in a wonderful children's hospital. If I asked you which side of this anoplasty did the fellow do, and which side did the faculty member do, what, what would your, what would your answer be? ↗
▶ Ep 41 · 11:58
quote Very good. You are ready for your fellowship. ↗
▶ Ep 41 · 12:35
clinical Patients with horrific diaper rash and perineal excoriation related to no dentate line and no intact sphincters need temporary stomas; some may need permanent stomas. ↗
▶ Ep 41 · 12:35
quote I mean, this is just absolutely the worst. These patients, there are two of them here, show a horrific diaper rash, perineal excoriation related to no dentate line, no intact sphincters. ↗
▶ Ep 41 · 12:48
quote These patients needed temporary stomas, and I think the one on the right needed a permanent stoma. ↗
▶ Ep 41 · 15:09
clinical In a soiling Hirschsprung patient with no obstruction, no distention, no enterocolitis, and 3 stools a day, that's a patient who needs management of a slow-moving colon. ↗
▶ Ep 41 · 19:10
quote I mean, the bottom line is we have solved the obstruction. The Hirschprung's is an obstruction problem. Now the tough part is getting them clean. Two separate and independent challenges. ↗
▶ Ep 41 · 19:10
clinical Hirschsprung disease is an obstruction problem; once that's solved, the tough part is getting patients clean—two separate and independent challenges. ↗
▶ Ep 41 · 19:22
quote Most of them get clean on their own. That's why Hirshprung's vast majority of patients have a great, great success stories. ↗
▶ Ep 41 · 19:22
clinical The vast majority of Hirschsprung patients get clean on their own and have great success stories. ↗
▶ Ep 41 · 19:30
clinical Clinicians need to determine if Hirschsprung patients are too slow or too fast, how to manipulate their motility, and understand if they have the mechanisms needed for continence (sphincters and dentate line). ↗
▶ Ep 41 · 19:30
quote But then we need to know, are they too slow or are they too fast? How do we manipulate their motility, and we need to understand inherently, do they have the mechanisms needed for continence, i.e., their sphincters and their dentate line. ↗
▶ Ep 41 · 20:00
clinical For hypermotile patients, skin care is vitally important; a cyanoacrylate-based barrier is very helpful. ↗
▶ Ep 41 · 20:12
clinical Wound care improvements for perineums in Hirschsprung or any hypermotile patient have dramatically improved over the last 4-5 years. ↗
▶ Ep 41 · 20:27
clinical Proton pump inhibitors are helpful to reduce the acidity of stool in hypermotile patients. ↗
▶ Ep 41 · 20:37
clinical Some antacid products can be taken orally as liquid and put on the skin to reduce acidity and help excoriation. ↗
▶ Ep 41 · 20:47
clinical Small volume enemas are a very helpful maneuver for hypermotile patients. ↗
▶ Ep 41 · 20:52
clinical Water-soluble fiber (not water-insoluble) produces bulky stool and is helpful for hypermotile patients. ↗
▶ Ep 41 · 21:05
clinical Loperamide is very helpful medicine for hypermotile patients; the maximum dose is 0.5 to 0.8 mg per kilogram divided daily based on patient weight. ↗
▶ Ep 41 · 21:24
clinical Cholestyramine is the next level of treatment after loperamide for hypermotile patients. ↗
▶ Ep 41 · 21:27
clinical Hyoscyamine (Levsin) 0.125 mg tablet every six hours has been used for hypermotile patients. ↗
▶ Ep 41 · 21:40
clinical Diphenoxylate-atropine (Lomotil) is almost never used because it has cardiac side effects. ↗
▶ Ep 41 · 21:55
clinical Tincture of opium is useful for slowing stool but is a controlled substance and difficult to get prescribed. ↗
▶ Ep 41 · 22:06
clinical If everything checks out with the pull-through and patients are still not emptying, Botox may be needed to help patients train and control their non-relaxing sphincters rather than being withholders. ↗
▶ Ep 41 · 24:49
quote But I will say, the hardest group of patients of all the soilers that we take care of. Which include anorectal malformation, Hirschsprung's, functional constipation, and spinal. The worst group, the hardest group is definitely Hirschprung's, without question, because the sphincters are so troublesome. ↗
▶ Ep 41 · 24:49
opinion Of all soiling patients (anorectal malformation, Hirschsprung, functional constipation, spinal), the hardest group is definitely Hirschsprung without question, because the sphincters are so troublesome. ↗
▶ Ep 41 · 25:09
quote Um, but of that group, the hypermodal are much harder than the hypomodal. ↗
▶ Ep 41 · 25:09
opinion Of Hirschsprung patients, the hypermotile are much harder to manage than the hypomotile. ↗
▶ Ep 41 · 25:14
quote But with strategies, you can really get a lot of these patients clean that were told they could never be clean. Um, if you sort of have your methodology, you know if they have potential for bowel control. And then you manipulate the motility as we've, as we've discussed. ↗
▶ Ep 41 · 25:14
opinion With systematic strategies—knowing if patients have potential for bowel control and manipulating motility accordingly—many Hirschsprung patients who were told they could never be clean can achieve cleanliness. ↗

Colorectal Quiz Episode 28: Female ARM Management - Perineal Fistula

▶ Ep 41 · 2:25
opinion Conversations about female perineal fistula management are more time-consuming than those about cloaca, and patients seek multiple opinions for this relatively benign malformation. ↗
▶ Ep 41 · 2:25
quote the conversations that go around a female, the perineal fistula are more time-consuming than the conversations that need to happen about a cloaca. ↗
▶ Ep 41 · 3:12
clinical If the hole is in the center of the sphincter with adequate lumen and a perineal body is present, the patient does not need surgery. ↗
▶ Ep 41 · 3:12
quote if the hole is in the center of the sphincter or it's in somewhat of the sphincter, and if the hole is enough of a lumen, and if there's a perineal body, that patient does not need to be touched. ↗
▶ Ep 41 · 3:24
clinical If the hole is too small or outside of the sphincter, surgery is required. ↗
▶ Ep 41 · 4:20
clinical There are five valid management options for perineal fistula: colostomy then repair, primary repair, dilation then repair, simultaneous colostomy and repair, and dilation alone. ↗
▶ Ep 41 · 5:23
clinical Diverting with a colostomy does not necessarily prevent perineal body dehiscence, and colostomy carries significant morbidity including closure complications. ↗
▶ Ep 41 · 5:23
quote diverting with a colostomy doesn't necessarily stop that from happening and You have the morbidity of a colostomy and of the colostomy closure, which is nothing to sneeze at. ↗
▶ Ep 41 · 5:46
quote this is not an emergency. They are passing stool, so the diversion of stool is not the reason for the colostomy, unless it's a very, very tiny fistula, and they can't pass stool, but that can be managed by, by dilation. ↗
▶ Ep 41 · 6:07
clinical Dilation alone is potentially acceptable but could be problematic if the fistulous distal end will not grow, leading to proximal distension. ↗
▶ Ep 41 · 7:38
clinical Anal stenosis (position 5 on the classification) requires screening for Currarino syndrome. ↗
▶ Ep 41 · 9:14
clinical A vestibular fistula is not a vaginal fistula because the posterior vaginal wall is intact with no fistula to it. ↗
▶ Ep 41 · 9:14
quote this vestibular fistula is not a vaginal fistula because the vaginal wall, the posterior vaginal wall is intact. There's no fistula to it. ↗
▶ Ep 41 · 9:34
epidemiological True vaginal fistulas are exceedingly rare in anorectal malformations. ↗
▶ Ep 41 · 10:50
clinical Some perineal fistulas (position 4 on the classification) can be managed with posterior wall mobilization without touching the anterior wall. ↗
▶ Ep 41 · 14:09
clinical Surgeons performing vaginoscopy should look for single versus duplicated cervix, distal vaginal atresia, and vaginal septum. ↗
▶ Ep 41 · 14:21
quote Incidence of vaginal atresia is quite rare, and vaginal septums are a little bit more common, somewhere around 3 to 5% of vestibulars. ↗
▶ Ep 41 · 14:21
epidemiological The incidence of distal vaginal atresia is quite rare in anorectal malformations. ↗
▶ Ep 41 · 14:28
epidemiological Vaginal septums occur in approximately 3 to 5% of vestibular fistulas. ↗
▶ Ep 41 · 14:36
clinical Perineal fistulas can be associated with distal vaginal atresia, though less commonly than vestibular fistulas. ↗
▶ Ep 41 · 16:36
clinical For patients with anorectal malformations and ureteral abnormalities, differential renal function assessment (such as DMSA scan) is important to determine whether to reimplant the ureter or remove a non-functional kidney. ↗
▶ Ep 41 · 17:20
quote absent kidney, quote unquote. And it's usually not absent, it's more non-functional and it's often multicystic and dysplastic, not absent ↗
▶ Ep 41 · 17:20
clinical Absent kidneys in anorectal malformation patients are usually not truly absent but rather non-functional, often multicystic and dysplastic. ↗
▶ Ep 41 · 17:44
guideline Every surgeon caring for anorectal malformations should know the malformation type, spinal status (tethered cord, myelomeningocele, or normal), and sacral anatomy including sacral ratio. ↗
▶ Ep 41 · 17:44
quote every surgeon takes care of an interectal malformation, ought to know the type of malformation, the status of the spine, i.e., tethered cord or myelomeningocele, or in most cases, luckily normal, and the status of the sacrum ↗
▶ Ep 41 · 18:15
clinical Sacral ratio calculation is valuable for informing family conversations about potential for bowel control in anorectal malformation patients. ↗
▶ Ep 41 · 18:15
clinical A patient with a low-type anorectal malformation (such as perineal fistula) but with associated spinal pathology has a different prognosis for bowel control than the same malformation with a normal spine. ↗
▶ Ep 41 · 18:15
quote this is an interesting patient with a very low type of malformation, however, with an associated spinal problem, and therefore their prognosis is not the same as a perineal fistula patient with a normal spine ↗

Colorectal Quiz Episode 29: Female ARM-Post Op Management

▶ Ep 42 · 1:17
quote So are you trying to say that I am a conservative surgeon because I may have a different protocol? ↗
▶ Ep 42 · 1:37
clinical Alberto Pena's original protocol mandated 7 days NPO with central line and hyperalimentation after ARM repair, feeding only on day 7 if healed. ↗
▶ Ep 42 · 2:42
quote And I had a fellow that said, why exactly are you keeping these patients NPO? ↗
▶ Ep 42 · 2:42
quote I had a fellow that said, why exactly are you keeping these patients NPO? And I said, well, because I don't want them to stool, because if they stool, they're more likely to hiss their perineal body. And the fellow said, you know, they still stool. Even if they're NPO. And I said yes, but not as much. ↗
▶ Ep 42 · 3:04
clinical A study by Carlos Reck (now in Vienna, Austria) compared NPO for 7 days versus clear liquids for 7 days and found the same amount of stool output in both groups. ↗
▶ Ep 42 · 3:10
quote I think it's about the same, and we studied it. ↗
▶ Ep 42 · 3:29
quote Same amount of poop. ↗
▶ Ep 42 · 3:30
clinical The problem is not stool passage itself but hard stool passage that can disrupt the perineal body anastomosis. ↗
▶ Ep 42 · 3:30
quote So then I came to the conclusion that it's not the pooping that's the problem, it's the hard pooping that's the problem. ↗
▶ Ep 42 · 3:37
clinical Dr. Levitt's current protocol is regular IV (no PICC line), clear liquids or breast milk for 5 days, with very low dehiscence rate. Day 5 provides better healing than day 1-2. ↗
▶ Ep 42 · 3:58
opinion There is no published article showing post-op day 1 regular diet (not breast milk, but actual food or formula) with a very low dehiscence rate. ↗
▶ Ep 42 · 5:45
quote And invariably, a perineal body dehiscence usually leads to no perineal body over several months, and needing for a redo because the anterior anoplasty has no sphincter around it, it's split. ↗
▶ Ep 42 · 5:45
clinical Perineal body dehiscence usually leads to no perineal body over several months, requiring redo surgery because the anterior anoplasty has no sphincter around it (it's split). ↗
▶ Ep 42 · 5:59
clinical Nearly every redo case Dr. Levitt sees for perineal body dehiscence involved patients who were fed right away and discharged home. ↗
▶ Ep 42 · 5:59
quote And every single one of those that I see nearly, I ask them what was the feeding protocol, and in invariably they were fed right away and discharged to home. ↗
▶ Ep 42 · 7:43
quote All right, my friend, give them clear liquids. You're gonna make a lot happier families and kids. We tested it. We have a nice paper about clear liquids. ↗
▶ Ep 42 · 9:06
clinical A randomized controlled trial by Richard Wood and Dr. Levitt compared dilation versus non-dilation for primary PSARP (cloacas excluded). Families were randomized and knew the backup plan for stricture was dilation ± Heineke-Mikulicz anoplasty. ↗
▶ Ep 42 · 9:06
quote Richard Wood and I ran a randomized controlled trial of dilation and non-dilation for primary PSAP. Cloacass were excluded, and families knew that they were going to be randomized into one of two groups, and the backup plan, if a patient developed um a stricture was dilation, plus or minus a Heineke McCulitz anoplasty. ↗
▶ Ep 42 · 9:33
clinical In the dilation trial, both groups (dilation and non-dilation) had stricture rates somewhere between 10 and 20%. ↗
▶ Ep 42 · 10:25
clinical Many patients' anoplasties look absolutely fine 8 weeks later at colostomy closure if they were never touched with a dilator, provided the anoplasty was healthy with no tension and good blood supply. ↗
▶ Ep 42 · 10:45
clinical The dilation study was prompted by asking families their biggest concern about ARM care, and by far number one was dilations. This was family-driven research, not doctor-driven problem-solving. ↗
▶ Ep 42 · 10:50
quote And what prompted the paper was, and this was Richard's idea, was to ask the families, what is their biggest concern relative to care of patients with an anorectal malformation, and by far, number one was dilations. ↗
▶ Ep 42 · 11:21
quote This was a real family-driven research. ↗
▶ Ep 42 · 11:25
clinical The non-dilation protocol offers families a choice: dilate twice daily for 4 months, or accept a 10-15% risk of stricture requiring Heineke-Mikulicz anoplasty, with the child already going under anesthesia in 8 weeks for colostomy closure. ↗
▶ Ep 42 · 13:45
clinical Jack Langer's protocol is to see patients weekly in clinic and pass a dilator himself rather than having families do it at home. ↗
▶ Ep 42 · 15:35
quote We don't know the answer to that question. That's a more longer term follow up. ↗
▶ Ep 42 · 15:58
quote Have you negatively affected their continence 3 years hence? And I don't know the answer to that question. ↗
▶ Ep 42 · 16:38
clinical Full continence can be restored with a redo operation for stricture, and data is available showing this. One indication for redo is stricture. ↗
▶ Ep 42 · 16:56
quote I personally have come to the conclusion that the amount of morbidity that we're putting families through by dilating them, and the minimal risk to them of even needing an intervention. And then if they do need an intervention, it's relatively minor, and the vast majority of those, they're already undergoing surgery for their colostomy closure. ↗
▶ Ep 42 · 17:12
clinical The vast majority of patients needing intervention for stricture in the non-dilation protocol are already undergoing surgery for colostomy closure, making the intervention relatively minor. ↗
▶ Ep 42 · 17:21
quote I can tell you, I have yet to, I have yet to meet a family that has chosen dilation. ↗
▶ Ep 42 · 17:21
clinical Dr. Levitt has yet to meet a family that has chosen dilation when presented with the non-dilation option and its risks/benefits. ↗
▶ Ep 42 · 18:31
quote I think the good news is that there's no right answer, we just have to all work together and suffer together on these difficult problems and try to, uh, improve lives as best we can. ↗
▶ Ep 42 · 19:37
clinical In Ghana, a colleague makes anoplasties slightly bigger knowing patients won't return for follow-up, anticipating some contraction will occur. ↗
▶ Ep 42 · 19:37
quote I asked him where, when would the patient come back for Clinic to start dilation. And he said, this patient will not be coming back for any follow-up. So therefore, he likes to make the anoplasty, and I know you've probably had this experience when you've been, been in the developing world, when he says, I make my anoplasties a little bit bigger, so that I know everything's gonna be fine when it contracts a little bit. ↗
▶ Ep 42 · 20:18
clinical For redo ARM cases, Dr. Levitt makes the anoplasty a little bigger knowing there will be contraction. Redos are not dilated at all, but are examined under anesthesia at one month to check for early stricture. ↗
▶ Ep 42 · 20:26
quote We don't dilate the redos, period. We EUA them at a month just to make sure no early stricture is developing. ↗
▶ Ep 42 · 20:33
quote In the primaries, I basically make the lumen what the rectum needs, what the maximal rectal lumen can be. And whatever that is, that fills the sphincter, that's how I make the anoplasty. ↗
▶ Ep 42 · 20:33
clinical For primary repairs, Dr. Levitt makes the lumen match what the maximal rectal lumen can be. With good mobilization (not overdoing it, throwing away as little rectum as possible), the anoplasty is usually a good size, about Hegar 13 or 14 at the end. ↗

Colorectal Quiz Episode 38: Transitional Care in Colorectal Surgery

▶ Ep 49 · 3:37
quote I encourage you to do examinations under anesthesia. This is a very valuable maneuver for ARM patients who have had a previous surgery. ↗
▶ Ep 49 · 3:37
clinical Examination under anesthesia is a valuable maneuver for ARM patients with previous surgery, allowing assessment of anoplasty prolapse, stricture, and proper location via electrical stimulation. ↗
▶ Ep 49 · 4:15
clinical In males, cystoscopy is added to evaluation to rule out remnant fistula and assess bladder mucosa and emptying; in females, cystoscopy can identify inappropriate fistulas. ↗
▶ Ep 49 · 5:28
clinical The functional problem is absence of sphincter anterior to the anoplasty: when the patient squeezes, the sphincter cannot close the anterior aspect and stool slips out, whereas proper concentric sphincter placement would successfully close the hole. ↗
▶ Ep 49 · 5:28
quote I was just going to say from a very functional point of view, what what's missing here is sphincters anterior to the anoplasty. ↗
▶ Ep 49 · 5:36
quote So when the patient with very good sphincters tries to squeeze those sphincters, they simply cannot close the anterior aspect of the anus, and stool can slip out of there, whereas if the anoplasty was properly located and the sphincter was concentric. They would successfully close the hole, and that's the incontinence problem ↗
▶ Ep 49 · 5:54
quote it's the most common problem in females that Jason and I have done redos for, uh, because there simply is no circle ↗
▶ Ep 49 · 5:54
clinical The most common problem in females requiring redo surgery is absence of a circular sphincter (an O), either from improper initial placement or dehiscence of the perineal body leaving a C-shaped sphincter; the surgical goal is to get muscle in front of the anus. ↗
▶ Ep 49 · 9:52
clinical The strategy of non-diversion with postoperative clear liquids (not NPO/TPN) produces soft watery stool that does not harm the perineal repair, whereas real food produces harder stool that can disrupt the repair; patients and families are much happier avoiding PICC lines and TPN. ↗
▶ Ep 49 · 10:22
quote my impression is that if you give someone real food. They make harder stool which can then blow through your perineal repair, whereas if you give the patient clear liquids, the stools that they produce are very soft and very watery, which don't do anything really to the wound care ↗
▶ Ep 49 · 10:55
clinical At 5 days, if perineal healing looks good, diet is advanced with laxatives to keep stool liquidy; the problem is hard stool going through the repair, not stool itself, as long as the wound is kept clean. ↗
▶ Ep 49 · 11:12
quote I think the problem is hard stool going through your repair, not stool. As long as you're keeping the wound clean, we have not had a problem, and I have not, uh, needed to divert, uh, such a patient. ↗
▶ Ep 49 · 16:03
opinion The ideal transition model begins psychologic discussion in early teenage years, engages friendly adult colleagues, and involves joint clinic visits and collaborative operating; most pediatric surgeons understand this because they have received calls from adult surgeons encountering unfamiliar pediatric conditions like malrotation. ↗
▶ Ep 49 · 17:16
opinion Not all pediatric colorectal surgeons need to physically operate in the adult setting if there are interested adult colleagues; in Jason Frischer's model, he has privileges at the adult hospital but functions primarily as an assistant while the adult surgeon (Ian Piquette) provides adult care expertise. ↗
▶ Ep 49 · 18:00
clinical In the United States, the age line for pediatric vs. adult care is very blurry, which is problematic; patients over age 21 (or possibly 18) at children's hospitals face credentialing issues where pediatric nurse practitioners cannot write orders due to licensing restrictions. ↗
▶ Ep 49 · 18:46
clinical If a 40-year-old at a children's hospital needs ICU care, the intensivists are pediatric-trained, not adult-trained, creating a safety concern. ↗
▶ Ep 49 · 20:11
opinion Bowel management expertise needs to be passed not just doctor-to-doctor but also nurse-to-nurse and advanced practice provider (NP/PA) to advanced practice provider. ↗
▶ Ep 49 · 20:23
opinion Adult colleagues should be introduced to the Malone appendicostomy (which many have never heard of) and the use of Peristeen for self-controlled enemas in adults; these are tricks learned in the pediatric population. ↗
▶ Ep 49 · 20:46
opinion In the United States, financial pressures favor operations, but many ARM patients do not require operations—they just need medical management that can change their life positively; one week of bowel management can achieve continence in a patient who has been soiling for decades. ↗
▶ Ep 49 · 21:11
opinion The presented case converted a patient with 27 years of fecal incontinence to normal bowel control by changing anatomy, but this is not always an option; medical management is important, and transition will require devoted colleagues not solely motivated by procedures. ↗
▶ Ep 49 · 23:25
opinion A patient-held 'passport' template documenting all previous surgical procedures, dates, and medical history should be created and distributed to parent organizations so each family is responsible for maintaining their own record to hand to any new care provider. ↗
▶ Ep 49 · 24:07
clinical Transitional care is being done well in several places worldwide, including Paris where pediatric and adult surgeons join each other's clinics for the first couple of visits. ↗

Colorectal Quiz: Episode 49 – Collaborating for Kids: Colorectal & Pelvic Solutions (with a Little Help from AI)

▶ Ep 59 · 2:41
quote I was expecting lots of errors and a very computer sounding experience, and it wasn't that at all. ↗
▶ Ep 59 · 3:00
quote The computer read, and I put that in quotes, the article fully and then knew what was coming later in the article to get us as the listener excited about it. ↗
▶ Ep 59 · 6:39
clinical A urologist produced a review article outline in minutes using Notebook LM with 30 articles, a task that previously took two weeks. ↗
▶ Ep 59 · 7:08
clinical AI can identify gaps in knowledge across a set of uploaded research articles. ↗

Colorectal Quiz: Episode 49 - Collaborating for Kids: Colorectal & Pelvic Solutions (with a Little Help from AI)

▶ Ep 75 · 0:00
quote we did something crazy i uploaded an article that jason frischer and i wrote together about the collaborative model in colorectal care published in seminars in pediatric surgery and loaded that article using ai into a podcast format ↗
▶ Ep 75 · 2:30
quote it foreshadowed things the computer read and i put that in quotes the article fully and then knew what was coming later in the article to get us as the listener excited about it ↗
▶ Ep 75 · 2:30
quote i was expecting lots of errors and a very computer sounding experience and it wasn't that at all it was a lovely two human sounding voices that were chatting about the article that jason and i wrote ↗
▶ Ep 75 · 5:47
clinical NotebookLM creates an expert from only the provided document, not pulling information from external sources like other chatbots. ↗

Colorectal Quiz: Episode 43

▶ Ep 79 · 3:53
quote It's very important to know the type of malformation, the quality of the sacrum, and the quality of the spine and give the patient's family some estimate of the likelihood that they will or not be continent. ↗
▶ Ep 79 · 8:09
quote I mean, I have to say, I'm sort of speechless that we're talking about physics with Jason Frischer. ↗
▶ Ep 79 · 13:14
epidemiological Small bowel volvulus around the appendix can occur but is rare, seen in only two or three cases. ↗
▶ Ep 79 · 14:31
clinical When doing a neo-Malone, try to orient the channel so the catheter enters into the right colon rather than refluxing into the ileum. ↗
▶ Ep 79 · 15:17
clinical When doing plication, pass the tube after each stitch to ensure it passes in the desired direction. ↗
▶ Ep 79 · 19:33
clinical Lone Star ring and pins can be placed in the umbilicus to get excellent exposure to visualize a tiny Malone hole. ↗
▶ Ep 79 · 20:31
clinical Ultrasound can be used to find the appendix around the umbilicus and needle localize the lumen for access rescue. ↗
▶ Ep 79 · 20:55
clinical Appendicitis in a Malone is impossible unless the hole closes, because there is no obstruction in pathophysiology. ↗
▶ Ep 79 · 20:59
quote It's impossible. Well, unless the hole closes. Unless the hole closes. ↗
▶ Ep 79 · 21:26
clinical In South Africa, appendix is never removed as part of laparoscopic appendectomy for appendicitis; it is a United States practice. ↗
▶ Ep 79 · 21:26
clinical Do not take out the appendix in a first Crohn's or ARM patient or a kid with spine issues or absent sacrum or spina bifida, as they may need it for future Malone or Mitrofanoff. ↗
▶ Ep 79 · 21:26
quote No one is obligating you to take out the appendix. And I will tell you, in South Africa, they never take out the appendix as part of a lads. It's just not done. It's a United States thing. ↗
▶ Ep 79 · 22:01
clinical Appendix tips should be sent to pathology because neuroendocrine tumors (carcinoids) can be found; one was discovered three months after pathology insisted on receiving specimens. ↗

Colorectal Quiz: Episode 43

▶ Ep 78 · 8:09
quote I have to say, I'm sort of speechless that we're talking about physics with Jason Frischer. ↗
▶ Ep 78 · 8:09
quote Frankly, what I learned from physics, you got to write it out every single step, prove to yourself that you can do it. And I think that's very appropriate for surgeons who are training. You've got to put yourself in the position. You got to say, can I do this by myself? Would I need help? And you got to get to that point. So I learned that life lesson the hard way in physics. ↗
▶ Ep 78 · 11:41
clinical When mesentery parallels the appendix, wrap cecum around appendix like a fundoplication; when mesentery is fenestrated, make one window at the bottom and plicate through that window to avoid crunching the mesentery. ↗
▶ Ep 78 · 13:21
epidemiological Small bowel volvulus around the appendix has been seen in two or three cases. ↗
▶ Ep 78 · 13:21
clinical Cecum should be positioned underneath the umbilicus without leaving a long-stemmed appendix hanging to reduce volvulus risk. ↗
▶ Ep 78 · 14:16
clinical When doing a neo-Malone, orient the channel so the catheter will enter into the right colon rather than refluxing into the ileum. ↗
▶ Ep 78 · 15:17
clinical During plication, pass the tube after every stitch to ensure it passes in the desired direction. ↗
▶ Ep 78 · 19:33
clinical Lone Star ring and pins can be placed in umbilicus to get exposure and visualize the Malone hole for catheterization. ↗
▶ Ep 78 · 20:31
clinical Ultrasound can be used to find the appendix around the umbilicus, then needle-localize the lumen ultrasound-guided to rescue malones. ↗
▶ Ep 78 · 20:55
clinical Appendicitis in a Malone is impossible unless the hole closes, because there is no obstruction in the pathophysiology. ↗
▶ Ep 78 · 20:59
quote It's impossible. Well, unless the hole closes. Unless the hole closes. ↗
▶ Ep 78 · 21:26
epidemiological In South Africa, appendix is never taken out as part of laparoscopic appendectomy; it is a United States practice. ↗
▶ Ep 78 · 21:26
clinical Appendix should not be removed in first Crohn's or ARM patients, kids with spine issues, absent sacrum, or spina bifida because they may need it for future Malone or Mitrofanoff. ↗
▶ Ep 78 · 22:01
clinical Appendix tissue should always be sent to pathology during Malone creation; one case had a carcinoid (neuroendocrine tumor) discovered three months later. ↗

Colorectal Quiz: Episode 40

▶ Ep 79 · 1:39
epidemiological Anorectal malformation occurs more commonly in females and has a prevalence of about one in 5,000 births. ↗
▶ Ep 79 · 2:21
clinical When you look in laparoscopically and see an end of the colon with nothing else visible, you do not have to do a divided colostomy—you can bring out that distal end as your stoma rather than interfering with the blood supply for the distal segment. ↗
▶ Ep 79 · 2:21
quote When you look in and you see an end of the colon and that's all you see, you do not have to do a divided colostomy. That can be the end. That can be your colostomy. ↗
▶ Ep 79 · 2:21
quote We've talked about this before on some of these rare circumstances. ↗
▶ Ep 79 · 2:59
quote I think the smartest thing to do in this very rare case is make a true end colostomy. ↗
▶ Ep 79 · 2:59
opinion The only potential benefit of doing a divided colostomy when encountering blind-ending colon is protecting the ultimate rectal repair, but this risks the blood supply to the distal rectum. ↗
▶ Ep 79 · 5:32
clinical Meyer-Rokitansky-Küster-Hauser syndrome can present with anorectal malformation, creating Meyer-Rokitansky-like anatomy where ovaries and remnant tubes are present but no midline Müllerian structures. ↗
▶ Ep 79 · 6:37
clinical The more common scenario of anorectal malformation with absent vagina is a recto-vestibular fistula with 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. ↗
▶ Ep 79 · 7:08
clinical In this case, the rectum ended blind and quite high in the pelvis, making it unreachable through a posterior sagittal incision. ↗
▶ Ep 79 · 7:18
clinical The foreshortened sacrum in this case suggests caudal regression, where everything below that level forgot to develop. ↗
▶ Ep 79 · 10:12
clinical Not diverting after limited posterior sagittal anorectoplasty is safe when you have a colocolonic anastomosis at the colostomy closure site and only an anoplasty with a couple of posterior sutures. ↗
▶ Ep 79 · 11:04
clinical In the past, vaginal replacement would have been done at the same time as rectal repair in these patients, but time and research have shown that colonic neovaginas are not great for patients 20 years down the road, and surgeons should try very hard to avoid them. ↗
▶ Ep 79 · 11:04
quote In the past, a vaginal replacement would have been done at the same time as the rectal repair in these patients. However, time and research have shown that colonic neovaginas are not great for patients 20 years down the road. And we should try very hard to avoid them. ↗
▶ Ep 79 · 11:35
clinical In most cloacas, you should be able to get the native vagina to reach without needing vaginal replacement. ↗
▶ Ep 79 · 11:35
quote I can tell you in most cloacas, you should be able to get the native vagina to reach. ↗
▶ Ep 79 · 12:46
host_summary A theoretical approach proposed by gynecologist Alison May for cloaca cases where native vagina doesn't reach is to provide a neovagina as a bridge so the patient can menstruate through it, then potentially remove it 20 years later. ↗
▶ Ep 79 · 14:50
clinical Vascular anomalies associated with anorectal malformation have not been much written about in the literature. ↗
▶ Ep 79 · 15:11
quote I vividly remember a case where we encountered an aberrant external iliac artery that looped up and actually was within the abdominal wall and looked very much like the obliterated umbilical artery and in fact was a blood supply to one of the extremities. ↗
▶ Ep 79 · 15:11
clinical An aberrant external iliac artery can loop up within the abdominal wall, looking very much like the obliterated umbilical artery, while actually being a blood supply to one of the extremities. ↗

Colorectal Quiz: Episode 40

▶ Ep 80 · 1:39
epidemiological Anorectal malformation occurs more commonly in females and has a prevalence of about one in 5,000 births. ↗
▶ Ep 80 · 2:21
quote When you look in and you see an end of the colon and that's all you see, you do not have to do a divided colostomy. That can be the end. That can be your colostomy. ↗
▶ Ep 80 · 2:21
clinical When laparoscopy reveals a blind-ending colon with no distal segment visible, an end colostomy is preferable to a divided colostomy to avoid interfering with blood supply to the distal rectum. ↗
▶ Ep 80 · 2:59
opinion The only potential benefit of a divided colostomy when a blind-ending colon is seen is protecting the ultimate rectal repair, but this risks the blood supply to the distal rectum. ↗
▶ Ep 80 · 5:32
clinical Meyer-Rokitansky-Küster-Hauser syndrome can occur with an anorectal malformation, though it is extremely rare. ↗
▶ Ep 80 · 5:35
quote It is Meyer-Rotakansky-like in that there are ovaries, there are scrawny little tubes, probably remnants, and then nothing else. No midline structure at all. ↗
▶ Ep 80 · 6:37
clinical The more common scenario is a recto-vestibular fistula with a completely normal urethra but no vagina in between (distal vaginal atresia), where the rectum ends as a fistula in the vestibule. ↗
▶ Ep 80 · 7:08
clinical In this case, the rectum ends blind and quite high in the pelvis, unreachable through a posterior sagittal incision. ↗
▶ Ep 80 · 7:18
clinical The sacrum appears foreshortened on imaging, suggesting caudal regression where everything below a certain level forgot to develop. ↗
▶ Ep 80 · 8:31
quote You couldn't safely dig through all those pulsating vessels with laparoscopes, right? ↗
▶ Ep 80 · 10:12
clinical Not diverting was considered safe because there was a colocolonic anastomosis at the colostomy closure site and only an analplasty with a couple of posterior sutures, unlike Hirschsprung's disease where distal obstruction from non-relaxing sphincters could blow out the anastomosis. ↗
▶ Ep 80 · 11:14
quote In the past, a vaginal replacement would have been done at the same time as the rectal repair in these patients. However, time and research have shown that colonic neovaginas are not great for patients 20 years down the road. ↗
▶ Ep 80 · 11:14
clinical In the past, vaginal replacement would have been done at the same time as rectal repair, but time and research have shown that colonic neovaginas are not great for patients 20 years down the road and should be avoided. ↗
▶ Ep 80 · 11:35
clinical In most cloacas, the native vagina should be able to reach and vaginal replacement should be avoided. ↗
▶ Ep 80 · 11:56
quote I think in 20 years or perhaps even shorter, we're going to have tissue engineering options. ↗
▶ Ep 80 · 11:56
clinical A buccal graft could be laid into the opened introitus area as an alternative to dilation. ↗
▶ Ep 80 · 12:34
opinion One can completely avoid vaginal replacement in these cases in the current era. ↗
▶ Ep 80 · 12:34
quote I think really in these, these days, one can completely avoid a vaginal replacement. ↗
▶ Ep 80 · 12:46
clinical Gynecologist Alison May proposed providing a neovagina as a temporary bridge so the patient can menstruate, with potential removal 20 years later when tissue engineering becomes available. ↗
▶ Ep 80 · 13:21
clinical Using the remaining colon in this patient for vaginal replacement would be very risky due to compromised blood supply from the prior divided stoma. ↗
▶ Ep 80 · 14:09
quote There's going to be a real estate problem. ↗
▶ Ep 80 · 15:11
clinical Mark Levitt recalls a case with an aberrant external iliac artery that looped up within the abdominal wall, resembling the obliterated umbilical artery but actually supplying blood to an extremity. ↗
▶ Ep 80 · 15:11
quote I vividly remember a case where we encountered an aberrant external iliac artery that looped up and actually was within the abdominal wall and looked very much like the obliterated umbilical artery and in fact was a blood supply to one of the extremities. ↗
▶ Ep 80 · 15:11
clinical Vascular anomalies associated with anorectal malformations have not been much written about in the literature. ↗
▶ Ep 80 · 17:13
opinion The odds of continence for this child are concerning given the anatomy. ↗
▶ Ep 80 · 17:13
quote The odds of continence for this child are concerning. ↗
▶ Ep 80 · 17:39
clinical The patient is not leaking urine all the time, which is a positive finding for future continence. ↗

Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies

▶ Ep 81 · 4:06
quote there is an anal dimple. That means... A raised area and a good change in color. Which means there's probably a good sphincter ↗
▶ Ep 81 · 4:06
clinical An anal dimple with raised area and good color change indicates there is probably a good sphincter. ↗
▶ Ep 81 · 4:41
quote I don't stand in the way when the NICU gets an echo. I routinely get them all ↗
▶ Ep 81 · 6:03
opinion Dilation and sending baby home is a suboptimal choice in a baby with no cardiac defect, but might be a good choice in a baby you don't want to take to the OR. ↗
▶ Ep 81 · 6:32
opinion If you could dilate a perineal fistula patient, you don't need to go to the OR at all and can let them deal with the heart. ↗
▶ Ep 81 · 6:32
clinical In a male perineal fistula, the hole isn't always easy to see and dilation is more dangerous because it's near the urethra, but with care and Hagar dilators you can get egressive stool and never go to the OR. ↗
▶ Ep 81 · 6:32
quote There's no rush on a vestibular. There's no rush on a perineal ↗
▶ Ep 81 · 6:32
clinical There is no rush on a vestibular fistula in a female patient or a perineal fistula, allowing time to address cardiac issues first. ↗
▶ Ep 81 · 8:13
quote I actually don't think there's a need to do a colostomy in a baby like this. You can dilate and then do the repair primarily later ↗
▶ Ep 81 · 8:13
opinion Colostomy is not any more or less risky than a one-hour mini-PSARP for perineal fistula. ↗
▶ Ep 81 · 8:13
opinion There is no need to do a colostomy in a baby with perineal fistula and cardiac disease; you can dilate and then do the repair primarily later. ↗
▶ Ep 81 · 9:43
quote Sort of a 95-5 percentage loop. It behaves like an end. And no one knows except for you that there's another side there you can do a contrast ↗
▶ Ep 81 · 9:43
clinical A turnable loop ostomy with 95-5 percentage behaves like an end colostomy, and no one knows except the surgeon that there's another side where you can do a contrast study. ↗
▶ Ep 81 · 11:00
clinical If the baby has an umbilical line, consider going into Palmer's Point instead of accessing through the umbilicus, using a Hasson technique. ↗
▶ Ep 81 · 12:33
quote This baby has a low lesion. So, basically, just had a closely approximated perineal fistula to the anal muscular complex. So, should do really well ↗
▶ Ep 81 · 12:33
clinical Important factors for continence include sensation in the anal canal, absence of the dentate line, quality of the spine, type of anorectal malformation, and sacral anatomy. ↗
▶ Ep 81 · 12:33
clinical Sacral ratio measurement should wait until 3 months of age. ↗
▶ Ep 81 · 12:33
clinical A baby with a low ARM lesion (closely approximated perineal fistula to anal muscular complex) should do really well with continence. ↗
▶ Ep 81 · 14:10
quote It's one millimeter deep. Do not dive in and try to find that fistula's tract. It will disappear, provided you have a good anoplasty with a good anterior rectal wall mobilization ↗
▶ Ep 81 · 14:10
clinical The perineal fistula tract is only one millimeter deep; do not dive in to find it as it will disappear with good anoplasty and anterior rectal wall mobilization. ↗
▶ Ep 81 · 14:57
clinical If the fistula is completely outside of the sphincteric ellipse, then full mobilization is required. ↗

Colorectal Quiz Episode 32: Anorectal Malformations And Cardiac Anomalies

▶ Ep 82 · 4:06
clinical An anal dimple with raised area and good color change means there's probably a good sphincter. ↗
▶ Ep 82 · 6:03
quote I think it's important to know how to do that because it might be a good choice in a baby who you don't want to take to the OR. ↗
▶ Ep 82 · 6:32
quote In a male, the perineal hole isn't always so easy to see. And the dilation is a little bit more dangerous because it's near the urethra. But with care and Hagar dilators, you can definitely get egressive stool and never go to the OR. ↗
▶ Ep 82 · 6:32
clinical For female patients with vestibular or perineal fistulas, there's no rush to operate; dilation can allow egressive stool without going to the OR. ↗
▶ Ep 82 · 6:32
clinical In males, the perineal hole isn't always easy to see and dilation is more dangerous because it's near the urethra, but with care and Hagar dilators you can achieve egressive stool. ↗
▶ Ep 82 · 8:13
opinion There's no need to do a colostomy in a baby with perineal fistula and cardiac disease; you can dilate and then do the repair primarily later, and colostomy is not more or less risky than a one-hour PSARP. ↗
▶ Ep 82 · 9:43
quote Sort of a 95-5 percentage loop. It behaves like an end. And no one knows except for you that there's another side there you can do a contrast. ↗
▶ Ep 82 · 9:43
clinical A turnable loop ostomy behaves like an end ostomy in a 95-5 percentage configuration, and no one knows except the surgeon that there's another side where you can do a contrast study. ↗
▶ Ep 82 · 11:08
clinical When accessing the umbilicus for laparoscopy, dissect in with a mosquito, make sure you're in without touching any vessel before insufflating, and clear the line of air. ↗
▶ Ep 82 · 14:02
clinical The raphe beads should be scraped off at one millimeter depth; do not dive in to find the fistula tract as it will disappear with good anoplasty and anterior rectal wall mobilization. ↗
▶ Ep 82 · 14:02
quote you've got to scrape that off. It's one millimeter deep. Do not dive in and try to find that fistula's tract. It will disappear, provided you have a good anoplasty with a good anterior rectal wall mobilization. ↗
▶ Ep 82 · 14:23
clinical For a 50-50 fistula (half within muscle complex, half anterior), leave the anterior wall as it's the danger zone, mobilize posteriorly to fill the anal sphincter, creating an 80-20 reconstruction; if the fistula is completely outside the sphincteric ellipse, full mobilization is required. ↗

Colorectal Quiz Episode 29: Female ARM

▶ Ep 83 · 1:13
clinical The problem is not pooping itself but hard pooping that can disrupt the perineal body repair. ↗
▶ Ep 83 · 1:13
clinical A study by Carlos Reck comparing NPO for seven days versus clear liquids for seven days found the same amount of stool output in both groups. ↗
▶ Ep 83 · 1:13
clinical Alberto Pena's historical protocol kept patients mandatory NPO for seven days with central line and hyperalimentation, feeding on day seven if healed. ↗
▶ Ep 83 · 1:13
clinical Dr. Levitt's current protocol is regular IV (no PICC line) and clear liquids or breast milk for five days, based on better healing by day five compared to day one or two. ↗
▶ Ep 83 · 5:23
clinical In redo cases seen by Dr. Levitt, patients were invariably fed right away and discharged home. ↗
▶ Ep 83 · 5:23
quote I think the key to this will be as minimal amount of perineal body injury by surgery as possible. ↗
▶ Ep 83 · 5:23
clinical Perineal body dehiscence usually leads to no perineal body over several months and requires redo surgery because the anterior anoplasty has no sphincter around it. ↗
▶ Ep 83 · 8:05
clinical A paper by Dr. Levitt found that clear liquids were no different than NPO in terms of stool output, but both groups still produced very thin, liquidy stool that would not disrupt the anastomosis. ↗
▶ Ep 83 · 9:05
clinical Many anoplasties that were never touched with a dilator look absolutely fine eight weeks later at colostomy closure if the repair was healthy with no tension and good blood supply. ↗
▶ Ep 83 · 9:05
clinical The dilation RCT was prompted by families identifying dilations as their biggest concern in caring for patients with anorectal malformation. ↗
▶ Ep 83 · 9:05
clinical A randomized controlled trial by Richard Wood and Dr. Levitt compared dilation versus non-dilation for primary PSARP (cloacas excluded), with backup plan of dilation plus or minus Heineke-Mikulicz anoplasty for strictures. ↗
▶ Ep 83 · 9:05
clinical The dilation RCT found that both dilated and non-dilated groups developed strictures somewhere between 10 and 20% of the time. ↗
▶ Ep 83 · 13:48
clinical Jack Langer's routine is to see patients every week in clinic and pass a dilator without having families do it at home. ↗
▶ Ep 83 · 14:04
clinical In the dilation RCT, four patients required redo operations for stricture: two in the dilation arm (both chose not to do dilations) and two in the non-dilation arm. ↗
▶ Ep 83 · 16:30
clinical Dr. Levitt has yet to meet a family that has chosen dilation when presented with the option of non-dilation with selective intervention. ↗
▶ Ep 83 · 16:30
clinical There is existing data showing that full continence can be restored with a redo operation, including for stricture as an indication. ↗
▶ Ep 83 · 18:31
quote I think the good news is that there's no right answer. We just have to all work together and suffer together on these difficult problems and try to improve lives as best we can. ↗
▶ Ep 83 · 19:37
clinical In primary repairs, Dr. Levitt makes the lumen match what the maximal rectal lumen can be, filling the sphincter, which is usually about a 13 or 14 Hegar size at the end. ↗
▶ Ep 83 · 19:37
clinical In redo cases, Dr. Levitt makes the anoplasty a little bigger knowing there will be contraction, and does not dilate redos but performs EUA at one month to check for early stricture. ↗
▶ Ep 83 · 19:37
clinical A surgeon in Ghana taught Dr. Levitt to make anoplasties a little bigger in cases where patients will not return for follow-up, knowing there will be some contraction. ↗

Colorectal Quiz Episode 29: Female ARM

▶ Ep 84 · 1:13
clinical Alberto Pena's historical protocol mandated 7 days NPO with central line and hyperalimentation, feeding on day 7 if healed. ↗
▶ Ep 84 · 2:23
clinical Carlos Reck (Vienna) studied stool output in NPO versus clear-liquid groups for 7 days and found the same amount of stool in both groups. ↗
▶ Ep 84 · 2:23
quote I had a fellow that said, why exactly are you keeping these patients NPO? And I said, well, because I don't want them to stool. Because if they stool, they're more likely to dehisc their perineal body. And the fellow said, you know, they still stool, even if they're NPO. And I said, yes, but not as much. And he said, this was Carlos Reck, who's now the premier colorectal surgeon in Austria. He's in Vienna. He said, I think it's about the same. And we studied it. And Carlos recorded stool output in two groups, NPO for seven days. And we gave them clear liquids. That was our test, clear liquids for seven days. And guess what? Same amount of poop. ↗
▶ Ep 84 · 3:30
clinical Levitt's current protocol is IV fluids (no PICC line) with clear liquids or breast milk for 5 days, based on conclusion that hard stool passage (not stool volume) causes dehiscence. ↗
▶ Ep 84 · 3:30
quote I remain very concerned about passage of hard stool. And I believe that one way to keep people from, kids from passing hard stool is to keep them on clear liquids. ↗
▶ Ep 84 · 5:23
clinical In Levitt's redo cases for perineal body dehiscence, patients were invariably fed right away and discharged home. ↗
▶ Ep 84 · 5:23
clinical Perineal body dehiscence usually leads to loss of perineal body over several months, requiring redo surgery because the anterior anoplasty has no sphincter around it. ↗
▶ Ep 84 · 9:05
clinical Wood-Levitt randomized controlled trial compared dilation versus non-dilation for primary PSARP (cloacas excluded), with backup plan of dilation under anesthesia plus/minus Heineke-Mikulicz anoplasty for strictures. ↗
▶ Ep 84 · 10:28
clinical In the dilation RCT, stricture rate was 10-20% in both dilation and non-dilation groups. ↗
▶ Ep 84 · 10:56
clinical Family surveys identified dilations as the number one concern for families of patients with anorectal malformations, prompting the dilation RCT. ↗
▶ Ep 84 · 10:56
quote What prompted the paper was, and this was Richard's idea, was to ask the families what is their biggest concern relative to care of patients with an anorectal malformation. And by far, number one was dilations. ↗
▶ Ep 84 · 10:56
clinical Many patients' anoplasties look absolutely fine 8 weeks later at colostomy closure if never touched with a dilator, assuming good technique (healthy tissue, no tension, good blood supply). ↗
▶ Ep 84 · 13:48
clinical Jack Langer's protocol involves seeing patients weekly in clinic and passing a dilator in office rather than having families dilate at home. ↗
▶ Ep 84 · 14:04
clinical In the dilation RCT, four patients required redo operations for stricture: two in the dilation arm (both chose not to dilate) and two in the non-dilation arm. ↗
▶ Ep 84 · 16:56
clinical Levitt has yet to meet a family that chose dilation when presented with the option of non-dilation with 10-15% stricture risk and Heineke-Mikulicz backup. ↗
▶ Ep 84 · 16:56
quote I can tell you, I have yet to meet a family that has chosen dilation. ↗
▶ Ep 84 · 19:37
clinical For redo anoplasties, Levitt makes the opening larger knowing there will be contraction; redo patients are not dilated but undergo EUA at one month to check for early stricture. ↗
▶ Ep 84 · 19:37
clinical For primary anoplasties, Levitt makes the lumen match the maximal rectal lumen that fills the sphincter, typically resulting in Hegar size 13-14. ↗
▶ Ep 84 · 19:37
clinical In Ghana, surgeons make anoplasties slightly larger knowing patients will not return for follow-up, accounting for expected contraction. ↗

Colorectal Quiz: Episode 2

▶ Ep 85 · 1:34
quote How many patients, Jason, have you seen on laxatives that comes with an anus in the wrong place? How many patients have you seen having had a cecostomy with perfect anatomy? ↗
▶ Ep 85 · 3:21
clinical The original malformation in case 1 was a prostatic fistula and the patient has a tethered cord with a sacral ratio of 0.66 ↗
▶ Ep 85 · 5:31
clinical Sacral ratio 0.7 or greater usually means normal sphincters and good muscle tone ↗
▶ Ep 85 · 5:31
quote the family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work, and is the child going to be clean and in normal underwear, and just like all the other kids. ↗
▶ Ep 85 · 5:31
clinical Patients with myelomeningocele have much more trouble with continence than those with tethered cord ↗
▶ Ep 85 · 5:31
clinical The higher the malformation, the worse the prognosis for bowel control ↗
▶ Ep 85 · 7:29
clinical A key pitfall is opening the PSARP incision first; instead, mark the sphincters first with electrical stimulation, then open the PSARP ↗
▶ Ep 85 · 7:29
quote a key pitfall is not do that. Mark the sphincters first, then open the PSARP, because then you don't get confused at the end when you're trying to place the analplasty in the correct location. ↗
▶ Ep 85 · 7:29
quote I'm looking for the anal dimple. And there's like a midline where I say, and there seems to be a little raised area, which is where the sphincters are and where the analplasty ought to be. ↗
▶ Ep 85 · 9:29
clinical The electrical stimulator used for sphincter mapping is the same one anesthesia uses for train of four ↗
▶ Ep 85 · 9:29
clinical Anesthesiologists should not give skeletal muscle relaxant when using the stimulator because it is weaker than traditional stimulators ↗
▶ Ep 85 · 11:38
host_summary Less common reasons for redo included remnant of original fistula (roof), rectal prolapse, and others ↗
▶ Ep 85 · 11:38
host_summary The average age of patients in the JPS study was about three and a half years ↗
▶ Ep 85 · 11:38
host_summary Twenty percent of patients with a poor sacrum or poor spine developed bowel control after their redo ↗
▶ Ep 85 · 11:38
host_summary Patients with good potential (good sacrum and spine) did extremely well after redo ↗
▶ Ep 85 · 11:38
host_summary In the JPS study, the vast majority of reoperations were for mislocation, followed by stricture ↗
▶ Ep 85 · 11:38
host_summary Patients had improved ability to achieve continence after redo ↗
▶ Ep 85 · 11:38
host_summary Patients who did not develop voluntary bowel movements after redo were still able to be clean with bowel management program using enemas or antegrade Malone ↗
▶ Ep 85 · 11:38
host_summary Quality of life improved with redo operations ↗
▶ Ep 85 · 13:28
opinion If anatomy is off, redo should be done, and there is an advantage to getting anatomy right when the child is younger ↗
▶ Ep 85 · 13:28
clinical After redo with Malone, patients learn to get control with new anatomy before stopping Malone flushes and trying voluntary bowel movements; this process may take six to twelve months ↗
▶ Ep 85 · 13:28
opinion For patients presenting after potty training age with incontinence due to mislocated anus, do the redo and usually add a Malone at the same time ↗
▶ Ep 85 · 13:28
opinion For a two-year-old with mislocated anus or bad prolapse, offer redo and let them live in diapers for a year or two with better anatomy before potty training ↗
▶ Ep 85 · 14:48
opinion For a patient with anus 50% within sphincter complex at age three and a half with incontinence, one approach is to redo and add Malone, get them clean mechanically, then see if they develop bowel control ↗
▶ Ep 85 · 15:45
opinion If patients haven't declared continence yet because they're not old enough behaviorally, give them a chance as they may succeed with current anatomy ↗

Colorectal Quiz: Episode 2

▶ Ep 86 · 1:34
quote How many patients, Jason, have you seen on laxatives that comes with an anus in the wrong place? How many patients have you seen having had a cecostomy with perfect anatomy? ↗
▶ Ep 86 · 1:34
clinical Many patients are seen on laxatives with an anus in the wrong place, and many patients have had cecostomy with perfect anatomy. ↗
▶ Ep 86 · 5:31
clinical Patients with myelomeningocele have much more trouble with continence than those with tethered cord. ↗
▶ Ep 86 · 5:31
clinical Higher anorectal malformations have worse prognosis for continence. ↗
▶ Ep 86 · 5:31
quote I can tell you, the family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work, and is the child going to be clean and in normal underwear, and just like all the other kids. ↗
▶ Ep 86 · 5:31
opinion Families care whether the anoplasty will work and whether the child will be clean and in normal underwear, not how technically elegant the surgery is. ↗
▶ Ep 86 · 5:31
clinical A sacral ratio of 0.7 or greater usually means normal or close to normal sphincters and good muscle tone, indicating that spine innervation of that area is probably good. ↗
▶ Ep 86 · 7:29
quote A key pitfall is not do that. Mark the sphincters first, then open the PSARP, because then you don't get confused at the end when you're trying to place the analplasty in the correct location. ↗
▶ Ep 86 · 7:29
quote It's amazingly common to have a mislocated anus. ↗
▶ Ep 86 · 7:29
clinical Visual inspection looks for the anal dimple and a midline raised area where the sphincters are and where the anoplasty ought to be. ↗
▶ Ep 86 · 7:29
clinical It is amazingly common to have a mislocated anus because surgeons either miss where the center is during laparoscopic pull-through or open the PSARP incision first before marking sphincters. ↗
▶ Ep 86 · 7:29
clinical A key pitfall is opening the PSARP incision first; instead, mark the sphincters first, then open the PSARP, to avoid confusion when placing the anoplasty. ↗
▶ Ep 86 · 9:29
clinical The electrical stimulator used for sphincter mapping is the same one anesthesia uses for train of four, with an inexpensive connection with little pins. ↗
▶ Ep 86 · 9:29
clinical Anesthesiologists should not give skeletal muscle relaxant when using the electrical stimulator because it is weaker than the traditional expensive stimulator. ↗
▶ Ep 86 · 11:38
host_summary Patients who did not develop voluntary bowel movements after redo were still able to be clean with a bowel management program using enemas or antegrade via Malone. ↗
▶ Ep 86 · 11:38
host_summary The average age of patients in the redo study was about three and a half years. ↗
▶ Ep 86 · 11:38
host_summary In the Journal of Pediatric Surgery study on reoperations for fecal incontinence after anorectal malformation repair, the vast majority of redos were for mislocation, followed by stricture. ↗
▶ Ep 86 · 11:38
host_summary Less common reasons for redo included remnant of original fistula (roof), rectal prolapse, and others. ↗
▶ Ep 86 · 11:38
host_summary Quality of life improved with a redo operation. ↗
▶ Ep 86 · 11:38
host_summary Patients had improved ability to achieve continence after redo operations. ↗
▶ Ep 86 · 11:38
host_summary In the study, 20% of patients with a poor sacrum or poor spine developed bowel control after their redo. ↗
▶ Ep 86 · 11:38
host_summary Patients with good potential (good sacrum and good spine) did extremely well after redo. ↗
▶ Ep 86 · 13:28
clinical For a two-year-old with mislocated anus or bad prolapse, offer a redo and let them live in diapers for a year or two with better anatomy, then see if they can successfully potty train. ↗
▶ Ep 86 · 13:28
clinical The process of learning control with new anatomy after redo may take six to twelve months. ↗
▶ Ep 86 · 13:28
opinion If the anatomy is known to be off, the redo should be done, and there is an advantage to getting the anatomy right when the child is younger. ↗
▶ Ep 86 · 13:28
clinical Many patients present after potty training age because they are incontinent, and evaluation reveals the reason is they did not have the best operation. ↗
▶ Ep 86 · 13:28
clinical When doing a redo for incontinence in an older child, usually add a Malone at the same time so they can learn to get control with their new anatomy before attempting voluntary bowel movements. ↗
▶ Ep 86 · 14:48
clinical For a patient with an anoplasty 50% within the sphincter complex at three and a half years old who is incontinent, one approach is to redo them, do a Malone, get them perfectly clean mechanically, then see if they can develop bowel control. ↗
▶ Ep 86 · 15:45
opinion If patients have not declared their continence yet because they are not old enough behaviorally, give them a chance as they may succeed. ↗

The Colorectal Quiz: Episode 1

▶ Ep 87 · 3:01
guideline VACTERL workup for anorectal malformations includes: V (vertebral abnormalities via plain x-ray), A (anorectal malformations), C (cardiac abnormalities via exam and echo), E (esophageal atresia via NG tube passage), R (renal abnormalities via kidney ultrasound), and L (limb abnormalities via physical exam) ↗
▶ Ep 87 · 3:01
quote I always worry about a missed pre-sacral mass. ↗
▶ Ep 87 · 3:01
quote V, vertebral abnormalities. Plain x-ray of the abdomen tells you about the spine, make sure there's no hemivertebra. A is anorectal malformations, which is why we're having this podcast. And then C, cardiac abnormalities. We want to make sure we check for any cardiac defect, both on exam and on echo. E is esophageal atresia. So they ought to get an NG2 pass. R for renal abnormalities. So they need a kidney ultrasound. And then L, limb abnormalities. ↗
▶ Ep 87 · 3:01
clinical Sacral ratio should be measured at three months of age for true measurement, though early measurement gives a feel for how normally the pelvis has developed ↗
▶ Ep 87 · 5:43
quote it's important that if this baby was born today, we're not rushing to do anything. Because we need time to have this baby declare themselves to either be someone who's going to need a colostomy or someone who might be able to benefit from a primary repair, a meconium, if a perineal fistula bubbles up. ↗
▶ Ep 87 · 7:08
quote I bet this kid is going to have a pretty normal sacral ratio, certainly greater than 0.7, which connotes a very good prognosis for bowel control and really peace of mind for the family. They want to know what's going to happen to this baby in four years when they need to potty train and go to school. ↗
▶ Ep 87 · 7:08
clinical Sacral ratio greater than 0.7 connotes very good prognosis for bowel control and provides peace of mind for families regarding potty training at age four ↗
▶ Ep 87 · 9:11
clinical The key to deciding whether to approach perineally via posterior sagittal is knowing where the rectum is—must be confident the first structure encountered will be rectum, not urethra, bladder neck, or bladder ↗
▶ Ep 87 · 9:11
quote I think the key to deciding whether to dive into a perineon posterior sagittally is where is the rectum? You want to know what structure you will find if you make a posterior sagittal or even a mini posterior sagittal incision. And there is no question in my mind that if I open posterior sagittally here, the first structure I would find would be rectum. Because the danger is that you go in posterior sagittally, you don't know where the rectum is, and you find something midline and white, like the urethra or the bladder neck or the bladder itself. And that's why we do colostomies. And that's why we do distal colostograms. So we know exactly where the rectum is, and we know whether we should approach it perineally or whether we should do it laparoscopically. ↗
▶ Ep 87 · 9:11
clinical Colostomies are done to know exactly where the rectum is via distal colostogram and to determine whether to approach perineally or laparoscopically ↗
▶ Ep 87 · 10:16
opinion The anal repair is made safer by having a colostomy, though everything in medicine is a balance ↗
▶ Ep 87 · 10:16
opinion Colostomy is the safe choice and was the right decision in this case, though it carries its own complications including those from colostomy closure ↗
▶ Ep 87 · 10:16
quote I will tell you that the surgeon who sent me this case, they did not do that. They felt more comfortable doing a colostomy. And I want to tell you, that was the safe thing to do. Bravo to them. That was the right choice. Nothing wrong with that at all. But of course, we are giving the child a colostomy. And whatever complications can happen from that, and we are giving the child a colostomy closure and whatever complications can happen from that. So everything in medicine is a balance, but there is no question that the anal part has been made safer by having a colostomy. ↗
▶ Ep 87 · 10:54
quote if you went in and grabbed this rectum and did a primary analplasty and did not know there was a fistula, and unfortunately, I've seen this done by some very good surgeons where they went in, did a beautiful analplasty, but ignored the fistula. And the child down the road started peeing out their anus. ↗
▶ Ep 87 · 10:54
clinical Very good surgeons have done beautiful anoplasties but ignored fistulas, resulting in children urinating out their anus postoperatively ↗
▶ Ep 87 · 12:00
quote when I do that, I open up the posterior wall of the rectum, and I inspect the anterior wall of the rectum. ↗
▶ Ep 87 · 12:00
clinical During primary posterior sagittal approach, open the posterior wall of rectum and inspect the anterior wall to rule out fistula ↗
▶ Ep 87 · 13:15
guideline Distal colostogram should still be performed in Down syndrome patients with imperforate anus despite 95% having no fistula ↗
▶ Ep 87 · 13:15
epidemiological 95% of Down syndrome patients with imperforate anus have no fistula, but 5% do have a fistula ↗
▶ Ep 87 · 13:15
quote 95% of Downs patients have no fistula, but 5% do. So I would still do a distal colostogram and some of them might have a fistula. ↗

The Colorectal Quiz: Episode 1

▶ Ep 88 · 3:01
guideline VACTERL mnemonic stands for: V (vertebral abnormalities), A (anorectal malformations), C (cardiac abnormalities), E (esophageal atresia), R (renal abnormalities), and L (limb abnormalities) ↗
▶ Ep 88 · 3:01
quote I always worry about a missed pre-sacral mass. ↗
▶ Ep 88 · 3:01
clinical True sacral ratio measurements should wait until the child is three months of age ↗
▶ Ep 88 · 3:01
clinical Cardiac evaluation should include both physical exam and echocardiogram in anorectal malformation patients ↗
▶ Ep 88 · 3:01
clinical NG tube should be passed to rule out esophageal atresia in anorectal malformation workup ↗
▶ Ep 88 · 3:01
clinical Plain x-ray of the abdomen can identify vertebral abnormalities including hemivertebra in anorectal malformation workup ↗
▶ Ep 88 · 3:01
clinical Kidney ultrasound is needed to evaluate for renal abnormalities in anorectal malformation patients ↗
▶ Ep 88 · 5:43
quote It's important that if this baby was born today, we're not rushing to do anything. Because we need time to have this baby declare themselves to either be someone who's going to need a colostomy or someone who might be able to benefit from a primary repair, a meconium, if a perineal fistula bubbles up. ↗
▶ Ep 88 · 7:08
quote The sacrum looks quite normal. I bet this kid is going to have a pretty normal sacral ratio, certainly greater than 0.7, which connotes a very good prognosis for bowel control and really peace of mind for the family. They want to know what's going to happen to this baby in four years when they need to potty train and go to school. ↗
▶ Ep 88 · 7:08
clinical A sacral ratio greater than 0.7 connotes a very good prognosis for bowel control ↗
▶ Ep 88 · 9:11
quote I think the key to deciding whether to dive into a perineon posterior sagittally is where is the rectum? You want to know what structure you will find if you make a posterior sagittal or even a mini posterior sagittal incision. ↗
▶ Ep 88 · 9:11
clinical The danger of blind posterior sagittal approach is finding midline white structures like urethra, bladder neck, or bladder itself instead of rectum ↗
▶ Ep 88 · 9:11
clinical Colostomy and distal colostogram are performed to know exactly where the rectum is and determine whether to approach perineally or laparoscopically ↗
▶ Ep 88 · 9:11
quote Because the danger is that you go in posterior sagittally, you don't know where the rectum is, and you find something midline and white, like the urethra or the bladder neck or the bladder itself. And that's why we do colostomies. And that's why we do distal colostograms. So we know exactly where the rectum is, and we know whether we should approach it perineally or whether we should do it laparoscopically. ↗
▶ Ep 88 · 9:11
clinical The key to deciding whether to approach perineally via posterior sagittal incision is knowing where the rectum is located ↗
▶ Ep 88 · 10:16
clinical Performing a colostomy is the safe choice and carries its own set of potential complications, as does colostomy closure ↗
▶ Ep 88 · 10:16
quote I will tell you that the surgeon who sent me this case, they did not do that. They felt more comfortable doing a colostomy. And I want to tell you, that was the safe thing to do. Bravo to them. That was the right choice. Nothing wrong with that at all. ↗
▶ Ep 88 · 10:54
clinical Surgeons have performed primary anorectoplasty without identifying a fistula, resulting in children later urinating out of their anus ↗
▶ Ep 88 · 10:54
quote This is sort of scary. Because if you went in and grabbed this rectum and did a primary analplasty and did not know there was a fistula, and unfortunately, I've seen this done by some very good surgeons where they went in, did a beautiful analplasty, but ignored the fistula. And the child down the road started peeing out their anus. ↗
▶ Ep 88 · 12:00
clinical During primary posterior sagittal approach, the posterior wall of the rectum should be opened and the anterior wall inspected to rule out fistula ↗
▶ Ep 88 · 12:00
quote I think that's the key point of this case, that I think a lot of people would have done a primary repair because they said, oh, that's a chip shot. The rectum's right there. But when I do that, I open up the posterior wall of the rectum, and I inspect the anterior wall of the rectum. ↗
▶ Ep 88 · 13:15
clinical Distal colostogram should still be performed in Down syndrome patients with imperforate anus despite the low probability of fistula ↗
▶ Ep 88 · 13:15
epidemiological 95% of patients with Down syndrome and imperforate anus have no fistula, but 5% do have a fistula ↗

Anorectal Malformations Complications

▶ Ep 89 · 2:55
quote You'd be surprised how common these malformations are not properly diagnosed or completely missed in the newborn period. ↗
▶ Ep 89 · 2:55
clinical Perineal fistulas in males are commonly missed in the newborn period because the baby passes meconium through the small fistulous opening, and no one notices the abnormal anal anatomy. These patients typically present in the first year of life with severe constipation. ↗
▶ Ep 89 · 3:43
clinical By the time a missed perineal fistula is diagnosed, the rectum and sigmoid have dilated because stool has been passing through a very tiny fistulous orifice which is not normal anal or rectal mucosa. ↗
▶ Ep 89 · 4:03
clinical The current standard is to check temperature on the forehead or in the ear rather than rectally, so if you don't look at the anus, you might not know there is a malformation. ↗
▶ Ep 89 · 4:03
quote Nowadays, the standard is to not even check a rectal temperature, is to check a temperature on the forehead or in the ear, and therefore, you don't have to look. If you don't look, you might not know. ↗
▶ Ep 89 · 4:53
clinical Relocating a perineal fistula into the sphincters does not completely fix the constipation, though it improves the anatomy by making the hole adequately sized and lined by mucosa. ↗
▶ Ep 89 · 5:23
clinical Patients with uncorrected perineal fistulas can have some semblance of continence with formed stool, but with loose stool or athletic activity they will soil because they cannot completely close the anteriorly located hole when squeezing their sphincters. ↗
▶ Ep 89 · 6:05
clinical A newborn anus should accept a size 12 Hagar dilator, and a one-year-old should accept a size 15. ↗
▶ Ep 89 · 6:41
clinical A bucket handle (a lifted skin tag that you can pass a probe underneath) is consistent with a perineal fistula even if you cannot see the fistula itself. ↗
▶ Ep 89 · 7:28
opinion Perineal fistula in females is probably the most confounding diagnosis in pediatric colorectal surgery, with many patients either being missed or overdiagnosed. ↗
▶ Ep 89 · 7:50
clinical Diagnostic criteria for perineal fistula in females: inadequate perineal body (hole too close to vagina), inadequate hole size, and hole not centered in the sphincter. ↗
▶ Ep 89 · 8:25
clinical If the anal opening in a female is adequate size and centered in the sphincter, even if it appears slightly anterior with a short perineal body, that patient does not need surgery. The perineal body will lengthen with growth. ↗
▶ Ep 89 · 9:10
quote It's very hard to improve on an asymptomatic patient. ↗
▶ Ep 89 · 10:50
clinical An anesthesia nerve stimulator ($150) with appropriate needle probes works as well as a dedicated Pena stimulator ($15,000) for intraoperative sphincter mapping. ↗
▶ Ep 89 · 11:30
quote I got no benefit from that $15,000 times two credit, but we use the anesthesia nerve stimulator. ↗
▶ Ep 89 · 12:38
clinical The vast majority of male ARM patients have a rectourethral fistula. It is important not to approach these primarily because you don't know where the rectum is—it could be at bladder neck, prostatic, or bulbar level. ↗
▶ Ep 89 · 13:20
clinical If you open posterior sagittal looking for a rectourethral fistula without knowing the location, you will find something midline, white, and shiny that might be the urinary tract, not the rectum. ↗
▶ Ep 89 · 14:04
quote Believe it or not, that has happened too. I just, in fact, last week saw a six-month-old who presented at age six months with constipation, and someone finally looked and saw there was no anus. ↗
▶ Ep 89 · 14:04
clinical Cloacas can be missed in the newborn period. Dr. Levitt saw a six-month-old who presented with constipation and was found to have an undiagnosed cloaca with no hint of an anal opening. ↗
▶ Ep 89 · 15:49
clinical Ambiguous genitalia (clitoromegaly from endocrine stimulation) presents with a urogenital sinus but a completely normal anus. This is different from a cloaca, which has no anus and no endocrine problem. ↗
▶ Ep 89 · 16:44
quote I think that operation of a colostomy needs to be taken very seriously, and every pediatric surgeon who deals with newborns, which is the art of our specialty, needs to be really, really good at this because there's a lot of morbidity that's conveyed to a patient with an improperly done colostomy. ↗
▶ Ep 89 · 16:44
clinical The most common colostomy error is opening too distal in the sigmoid, which restricts the ultimate pull-through by the location of the colostomy or mucous fistula. ↗
▶ Ep 89 · 17:20
clinical Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections. ↗
▶ Ep 89 · 17:50
clinical Transverse colostomies are problematic because they can prolapse, and if there is a large rectourethral fistula, the left colon absorbs all the urine (which doesn't come out the mucous fistula), causing acidosis. ↗
▶ Ep 89 · 18:35
clinical Dr. Levitt's preference is a very proximal sigmoid colostomy with separated stomas, leaving the entire sigmoid loop for the pull-through. He makes the mucous fistula very tiny and flat. ↗
▶ Ep 89 · 19:58
clinical Prolapse is related to where in the colon you choose to do the colostomy. Mid-transverse: both sides can prolapse. Hepatic flexure: only distal can prolapse. Proximal sigmoid: only distal (mucous fistula) can prolapse because left colon is fixed to retroperitoneum. ↗
▶ Ep 89 · 21:10
clinical Dr. Levitt marks the anoplasty location by drawing a circle around the pinkish ellipse where it stimulates on the skin surface BEFORE making the incision, to avoid getting lost when looking at jumping muscles from the stimulator. ↗
▶ Ep 89 · 21:10
quote I actually mark the anoplasty before I make the incision. And I think you can get lost when you're looking at a bunch of jumping muscles from a stimulator. ↗
▶ Ep 89 · 22:36
clinical Really good surgeons have put anuses in crazy places because they don't have a sense of what's the center once everything is disrupted and open. ↗
▶ Ep 89 · 22:36
quote I'm sure that's what's happened because really, really good surgeons have put anuses in crazy places. And I think it's because they don't have a sense of what's the center because everything's disrupted once it's open. ↗
▶ Ep 89 · 23:29
quote The distal colostagram is really an absolutely vital study. And a lot of mistakes are made because of a poorly done study, first of all, and then a misinterpretation of that study. ↗
▶ Ep 89 · 23:29
clinical The distal colostogram is an absolutely vital study. Many mistakes are made because of a poorly done study and misinterpretation. ↗
▶ Ep 89 · 23:55
clinical The basic questions the distal colostogram must answer: Where is the rectum? How low is it? Is it reachable posterior sagittally or better approached laparoscopically? What is its relationship to the urinary tract? ↗
▶ Ep 89 · 24:30
clinical The common colostogram mistake is not giving enough contrast and pressure into the distal segment, giving a false impression that the rectum is high or that there is no fistula. ↗
▶ Ep 89 · 25:00
clinical If you see a straight line flattening of the rectum corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure. You need to overcome the PC line (the sphincters compressing the distal rectum) to see the bulging rectum and fistula. ↗
▶ Ep 89 · 25:00
quote If you see that flattening of the rectum, you know the radiologist did not give enough contrast, enough pressure. Because you need to overcome the PC line because that's the sphincters. ↗
▶ Ep 89 · 25:55
clinical If the rectum is bulbous, it might be reachable posterior sagittally and hard to do laparoscopically because of the girth. If it's tapered, you're better off laparoscopically. ↗
▶ Ep 89 · 25:55
clinical Fistula classification: if the fistula is at the urethral 'elbow' or below, it's bulbar. Above the elbow is prostatic. At the bladder neck is bladder neck fistula. ↗
▶ Ep 89 · 26:52
clinical If you don't know where the rectum is and open posterior sagittal, you will find a whitish, shiny structure and may think it's the rectum. Often it's the bladder neck. ↗
▶ Ep 89 · 27:30
clinical You avoid bladder neck injury by knowing exactly where the rectum is from a properly done distal colostogram. When you open posterior sagittal, you know the rectum is right under the coccyx (prostatic) or distal to the coccyx (bulbar), or it isn't posterior sagittal at all (bladder neck—do laparoscopy). ↗
▶ Ep 89 · 29:20
quote You should never go to the operating room without knowing exactly what anatomy you're going to expect to find. And the big question is, where is the rectum? Is it the most posterior structure? And where is it the most posterior structure? ↗
▶ Ep 89 · 30:03
clinical Dr. Levitt will do posterior sagittal for bulbar fistulas and low prostatic fistulas with a bulge. High prostatic with tapered rectum and bladder neck fistulas are best served by laparoscopy. ↗
▶ Ep 89 · 30:50
clinical If you try laparoscopy for a rectum bulging below the peritoneal reflection at low prostatic or bulbar level, you may leave behind a remnant of the original fistula (ROOF)—the distal rectum left behind that causes trouble later. ↗
▶ Ep 89 · 31:38
clinical Laparoscopy replaces laparotomy, not PSARP. Dr. Levitt does a mini-PSARP when doing laparoscopy to safely enter the pelvis and tack the rectum to the posterior edge of the muscle complex to avoid prolapse. ↗
▶ Ep 89 · 31:38
quote I never look at it that way. I think that laparoscopy replaces laparotomy. It's an elegant dissection from above. But don't give away the advantages of the PSARP. ↗
▶ Ep 89 · 32:30
clinical Dr. Levitt calls his approach 'laparoscopic-assisted PSARP' rather than pure laparoscopy. ↗
▶ Ep 89 · 32:30
quote I like to call mine a laparoscopic-assisted PSARP. I think that's a better terminology. ↗
▶ Ep 89 · 32:55
clinical Prolapse prevention: put the rectum in the right location, close the levators properly, close the posterior wall to the posterior edge of the muscle complex for 3-4 stitches, don't dissect the rectum more than necessary. ↗
▶ Ep 89 · 33:49
epidemiological Prolapse occurs in about 3% of cases, particularly in those without great muscles. ↗
▶ Ep 89 · 33:54
clinical Rectal prolapse causes bleeding, mucus, and for patients with good continence potential, it inhibits bowel control because they can't close the opening with prolapsed tissue through it. ↗
▶ Ep 89 · 34:30
clinical Dr. Levitt trims prolapse of more than about 3mm. For circumferential prolapse, he does half the circumference in two different ambulatory settings so families don't need hospitalization and the patient doesn't need dilation (half the circumference is untouched so they won't stricture). ↗
▶ Ep 89 · 35:27
clinical Perineal body dehiscence is the most common cause of reoperation Dr. Levitt performs in female ARM repairs. ↗
▶ Ep 89 · 35:27
quote Perineal body dehiscence is the most common cause of reoperation that I do is a female repair in which the perineal body dehiscs. ↗
▶ Ep 89 · 35:55
clinical The key to preventing perineal body dehiscence is mobilizing the rectum well—you must get the anterior rectal wall completely separated from the posterior vaginal wall to the areolar plane. If you don't, the anoplasty will be under tension and can pull back, leak into the perineal body space, and dehisce. ↗
▶ Ep 89 · 36:50
clinical Dr. Levitt uses 3-0 suture for perineal body closure in a baby and 4-0 Vicryl on the perineal skin, then watches the perineum very closely. ↗
▶ Ep 89 · 37:15
clinical Traditionally Dr. Levitt kept patients NPO for 7 days on 10% dextrose after female ARM repair. Recently he has been trialing clear liquids only for a week because the major problem is hard stool—clear liquids won't make hard stool. ↗
▶ Ep 89 · 37:47
quote If you see it's opening, I actually will take... And this happens maybe one or two cases out of about 200, I can tell you. That's not insignificant. I will take them back to the OR and re-suture the perineal body. ↗
▶ Ep 89 · 37:47
clinical If perineal body dehiscence is detected on days 5-8, Dr. Levitt will take the patient back to the OR and re-suture the perineal body, which can salvage the situation. This happens in maybe 1-2 cases out of about 200. ↗
▶ Ep 89 · 38:31
clinical Laparoscopy causes trouble if you try to dissect a rectum that's too low—you get too close to the urinary tract or you're too timid and leave behind the distal rectum (remnant of original fistula). ↗
▶ Ep 89 · 39:10
clinical For high rectums, particularly bladder neck fistulas, the dissection of the distal rectum is quite challenging to make it reach with good blood supply. You must preserve the IMA because the colostomy may have disrupted collaterals down the left colic, making the rectum completely dependent on the IMA. ↗
▶ Ep 89 · 39:40
clinical The rectum has an excellent intramural blood supply from the IMA. If you take the IMA or take branches too close to the aorta, the rectum will die because there's no collateralization down the left colic. ↗
▶ Ep 89 · 40:12
clinical The biggest problem with posterior sagittal incision is going after a rectum when you don't know where it is. You open and find the bladder neck, urethra, seminal vesicles, vas deferens, ectopic ureter—everything but the distal rectum. ↗
▶ Ep 89 · 40:50
quote There are some famous cases of pull through bladder neck made into beautiful anoplasties. And post-op, the patient was draining liquid out their anoplasty. And in fact, it was the bladder neck. ↗
▶ Ep 89 · 40:50
clinical There are famous cases of pull-through of bladder neck made into beautiful anoplasties, and post-op the patient was draining liquid out their anoplasty—it was the bladder neck. ↗
▶ Ep 89 · 42:09
clinical To determine if an ARM patient has potential for bowel control, Dr. Levitt looks at three factors: original type of malformation, quality of sacrum and calculated sacral ratio, and quality of spine. He calls this the ARM continence index. ↗
▶ Ep 89 · 43:10
clinical Three A's (excellent malformation type, sacrum, and spine) predicts a continent patient. Three C's predicts an incontinent patient. Dr. Levitt's group is working on quantifying the in-between grades. ↗
▶ Ep 89 · 43:45
clinical A bulbar fistula with a good sacrum (sacral ratio of 1) and normal spine should absolutely have bowel control. A bladder neck fistula with poor sacrum (sacral ratio 0.4) and tethered cord or myelomeningocele has no real chance of good bowel control. ↗
▶ Ep 89 · 44:30
clinical For a soiling 4-year-old ARM patient, Dr. Levitt's first step is to get them clean mechanically with bowel management using enemas. For those with continence potential, when they're older and more mature, he tries to switch them to laxatives to achieve voluntary bowel movements. ↗
▶ Ep 89 · 45:20
clinical Indications for redo pull-through: any patient with potential for bowel control whose anatomy is not perfect—improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum). ↗
▶ Ep 89 · 46:05
opinion One of the biggest problems with ARM is that if you don't get it right, you don't know for a few years. Most surgical problems become obvious immediately, but with ARM, patients may not present with soiling until age 4, making it hard for surgeons to learn what to fix about their technique. ↗
▶ Ep 89 · 46:20
quote Most things in surgery, if you don't do it right, you know right away. Like, if you don't sew a hepatic artery together properly during a liver transplant, the next day, you have a thrombosed artery. If you don't put an anus in the right place, you think you did a perfectly fine operation, the patient goes home, everyone's happy, and only four years later do they come soiling. ↗

Anorectal Malformations Complications

▶ Ep 90 · 2:55
clinical Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period. ↗
▶ Ep 90 · 3:05
clinical Males with missed perineal fistula typically present in the first year of life with severe constipation after passing meconium through a very tiny fistulous orifice. ↗
▶ Ep 90 · 3:40
clinical By the time of presentation, the rectum and sigmoid have dilated because stool has been passing through a very tiny fistulous orifice which is not normal anal or rectal mucosa. ↗
▶ Ep 90 · 4:10
clinical The current standard is to check temperature on the forehead or in the ear rather than rectally, which means clinicians may not look at the anus and might not detect malformations. ↗
▶ Ep 90 · 4:30
quote If you don't look, you might not know. ↗
▶ Ep 90 · 4:53
clinical Relocating a perineal fistula into the sphincters does not completely fix constipation, though it improves anatomy by making the hole adequately sized and lined by mucosa. ↗
▶ Ep 90 · 5:20
clinical Patients with uncorrected perineal fistula can have some semblance of continence with formed stool, but will soil with loose stool or athletic activity because they cannot completely close the hole when squeezing sphincters. ↗
▶ Ep 90 · 6:05
clinical A newborn anus should accept a size 12 Hagar dilator, and a one-year-old should accept a size 15. ↗
▶ Ep 90 · 6:41
clinical A bucket handle (lifted skin tag that a probe can pass underneath) is consistent with a perineal fistula even when the fistula itself is not visible. ↗
▶ Ep 90 · 7:05
clinical Little beads of meconium (black) or mucus (white) along the scrotal raphae are consistent with a perineal fistula. ↗
▶ Ep 90 · 7:51
clinical Diagnostic criteria for perineal fistula in females: hole too close to vagina (inadequate perineal body), inadequate hole size, or hole not centered in sphincter. ↗
▶ Ep 90 · 8:40
clinical If the hole is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, the patient does not need surgery—the perineal body will lengthen with growth. ↗
▶ Ep 90 · 9:10
quote It's very hard to improve on an asymptomatic patient. ↗
▶ Ep 90 · 9:51
clinical Examination under anesthesia with stimulation can confirm whether a questionable hole is properly centered within the sphincter. ↗
▶ Ep 90 · 10:50
clinical An anesthesia nerve stimulator ($150) with appropriate needle probes works as well as commercial Peña stimulators ($15,000). ↗
▶ Ep 90 · 12:38
epidemiological The vast majority of male ARM patients have a rectourethral fistula at bladder neck, prostatic, or bulbar level. ↗
▶ Ep 90 · 12:55
opinion Rectourethral fistula patients should not be approached primarily because the surgeon does not know where the rectum is; colostomy with distal colostogram is safer. ↗
▶ Ep 90 · 13:20
clinical With posterior sagittal incision for unknown rectal location, the surgeon will find something midline, white, and shiny that might be urinary tract rather than rectum. ↗
▶ Ep 90 · 13:40
clinical With laparoscopy, all rectourethral fistulas go slightly below the peritoneal reflection, making it impossible to distinguish bladder neck, prostatic, or bulbar level. ↗
▶ Ep 90 · 15:49
clinical Cloaca patients have no anus and a urogenital sinus but have two completely normal ovaries with no endocrine problem. ↗
▶ Ep 90 · 16:34
clinical Urogenital sinus with normal anus is a unique entity often dealt with by urologists, distinct from cloaca. ↗
▶ Ep 90 · 17:04
clinical The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through by the location of the colostomy or mucous fistula. ↗
▶ Ep 90 · 17:30
clinical Incompletely dividing loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections. ↗
▶ Ep 90 · 18:15
clinical Transverse colostomies can prolapse and, with large rectourethral fistula, cause the left colon to absorb urine (which doesn't exit the mucous fistula), leading to acidosis. ↗
▶ Ep 90 · 18:45
clinical Distal colostogram through transverse colostomy is difficult because it requires high pressure and the entire distal segment is filled with meconium that's hard to clean out. ↗
▶ Ep 90 · 19:10
opinion Levitt's preference is proximal sigmoid colostomy with separated stomas, leaving the entire sigmoid loop for pull-through, with tiny flat mucous fistula. ↗
▶ Ep 90 · 20:03
clinical Prolapse location depends on colostomy site: mid-transverse (both sides), hepatic flexure (distal only), proximal sigmoid (distal only because left colon is fixed to retroperitoneum). ↗
▶ Ep 90 · 20:40
clinical Ileostomies prolapse frequently because they are free-floating unless tacked to the anterior abdominal wall. ↗
▶ Ep 90 · 21:10
clinical Levitt marks the anoplasty location by drawing a circle around the pinkish sphincter ellipse on the skin surface before making any incision to avoid getting lost when muscles are jumping from stimulation. ↗
▶ Ep 90 · 23:03
clinical Really good surgeons have put anuses in incorrect locations because they don't have a sense of center once everything is disrupted and open. ↗
▶ Ep 90 · 23:29
opinion The distal colostogram is an absolutely vital study; mistakes are made from poorly done studies and misinterpretation. ↗
▶ Ep 90 · 23:50
clinical The basic colostogram questions are: where is the rectum, how low is it, is it reachable posterior sagittally or better approached laparoscopically, and what is its relationship to the urinary tract. ↗
▶ Ep 90 · 24:20
clinical Common colostogram error: insufficient contrast and pressure give false impression that rectum is high or that there's no fistula. ↗
▶ Ep 90 · 24:40
clinical If the distal colostogram shows a straight line at the bottom of the rectum corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure to overcome sphincter compression. ↗
▶ Ep 90 · 25:20
clinical With adequate pressure, the colostogram shows a bulging rectum at the bottom and evidence of a fistula, revealing exactly where the rectum is. ↗
▶ Ep 90 · 25:45
clinical Fistula classification: if at the urethral 'elbow' or below, it's bulbar; above the elbow is prostatic; at bladder neck is bladder neck fistula. ↗
▶ Ep 90 · 26:52
clinical If opening posterior sagittal without knowing rectal location, the surgeon will find a whitish shiny structure that might be bladder neck rather than rectum. ↗
▶ Ep 90 · 27:40
clinical When opening posterior sagittal for rectourethral fistula, if the rectum is right under the coccyx it's usually prostatic; distal to coccyx is usually bulbar. ↗
▶ Ep 90 · 28:05
opinion Bladder neck fistulas are not reachable posterior sagittally and are better approached laparoscopically, as are very high prostatic fistulas with tapered rectums. ↗
▶ Ep 90 · 28:31
opinion Bulbar and bulbous prostatic fistulas can be found right under the coccyx and are preferably done posterior sagittally rather than laparoscopically. ↗
▶ Ep 90 · 28:50
clinical Some surgeons use a catheter with balloon in the mucous fistula or a gastroscope to look for light intraoperatively to locate the rectum, though Levitt doesn't use these techniques. ↗
▶ Ep 90 · 29:20
opinion Surgeons should never go to the operating room without knowing exactly what anatomy to expect; the key question is where is the rectum and is it the most posterior structure. ↗
▶ Ep 90 · 30:03
opinion Bulbar or low prostatic fistulas with bulging rectum are more easily approached posterior sagittally; high prostatic with tapered narrow rectum is best served by laparoscopy. ↗
▶ Ep 90 · 30:35
clinical Attempting laparoscopy for bulging rectum below peritoneal reflection (low prostatic/bulbar) requires unnecessary extra work and risks leaving behind a remnant of the original fistula (ROOF). ↗
▶ Ep 90 · 31:10
opinion Attempting posterior sagittal approach for high rectum is very difficult to mobilize and risks urinary tract injury; these cases are best served laparoscopically. ↗
▶ Ep 90 · 31:38
clinical Levitt performs a mini-PSARP when doing laparoscopy to safely enter the pelvis through the peritoneal reflection and to tack the rectum to the posterior edge of the muscle complex to avoid prolapse. ↗
▶ Ep 90 · 32:25
clinical Prolapse is very common after laparoscopic pull-through if the rectum is not hitched to the pelvis or tacked to the muscle complex. ↗
▶ Ep 90 · 32:40
quote I like to call mine a laparoscopic-assisted PSARP. ↗
▶ Ep 90 · 33:03
clinical Prolapse prevention measures include: putting rectum in right location, properly closing levators, closing posterior wall to posterior edge of muscle complex for 3-4 stitches, and not over-dissecting the rectum. ↗
▶ Ep 90 · 33:40
epidemiological Prolapse occurs in about 3% of cases, particularly in those without great muscles. ↗
▶ Ep 90 · 33:54
clinical Rectal prolapse causes bleeding, mucus, and can inhibit bowel control in patients with good potential because they cannot close the opening with prolapsed tissue through it. ↗
▶ Ep 90 · 34:30
clinical Levitt treats prolapse of more than 3mm, trimming it ideally while the colostomy is still in place. ↗
▶ Ep 90 · 34:50
clinical For circumferential prolapse, Levitt performs half the circumference in two different ambulatory settings, which families prefer to hospitalization and eliminates need for dilation since half the circumference is untouched. ↗
▶ Ep 90 · 35:35
epidemiological Perineal body dehiscence is the most common cause of reoperation in female ARM repairs. ↗
▶ Ep 90 · 35:50
clinical The key to preventing perineal body dehiscence is complete mobilization of the anterior rectal wall from the posterior vaginal wall to reach the areolar plane and avoid tension on the anoplasty. ↗
▶ Ep 90 · 36:20
clinical Levitt uses 3-0 suture for perineal body closure in babies and 4-0 Vicryl on perineal skin. ↗
▶ Ep 90 · 36:35
clinical Levitt traditionally used 7-day NPO on 10% dextrose but is now trialing clear liquids only for a week, recognizing the major problem is hard stool rather than stool volume. ↗
▶ Ep 90 · 37:10
clinical The major risk of regular diet and early discharge is hard stool passing through the repair, splitting it open and causing dehiscence. ↗
▶ Ep 90 · 37:47
clinical If perineal body dehiscence is detected on days 5-8, Levitt takes the patient back to OR to re-suture, which can salvage the situation; by 3-4 weeks the whole thing is dehisced and nothing can be done. ↗
▶ Ep 90 · 38:38
clinical Laparoscopy causes trouble if attempting to dissect a rectum that's too low, risking getting too close to urinary tract or being too timid and leaving behind remnant of original fistula. ↗
▶ Ep 90 · 39:10
clinical Passage of trocar through small perineal incision is risky; Levitt makes a 3-4cm posterior sagittal incision and hugs the hollow of the sacrum for safer passage into the pelvis. ↗
▶ Ep 90 · 39:40
clinical For high rectums (especially bladder neck fistulas), dissection of distal rectum is challenging to achieve adequate reach with good blood supply. ↗
▶ Ep 90 · 40:00
clinical The IMA must be preserved because prior colostomy disrupted collaterals down the left colic, making the rectum completely dependent on the IMA. ↗
▶ Ep 90 · 40:20
clinical The rectum has excellent intramural blood supply from the IMA; taking the IMA or branches too close to the aorta will cause rectal necrosis due to lack of collateralization. ↗
▶ Ep 90 · 40:46
clinical The biggest PSARP problem is operating without knowing where the rectum is, leading to finding bladder neck, urethra, seminal vesicles, vas deferens, or ectopic ureter instead of distal rectum. ↗
▶ Ep 90 · 41:15
clinical Famous cases exist of pull-through of bladder neck made into beautiful anoplasties, with the patient draining liquid (urine) postoperatively. ↗
▶ Ep 90 · 42:09
clinical Continence potential in ARM patients is assessed using three factors: original malformation type, sacral quality/sacral ratio, and spine quality (ARM continence index). ↗
▶ Ep 90 · 42:40
quote I like to call that the ARM continence index. ↗
▶ Ep 90 · 42:50
clinical Three A's (excellent in all three factors) predicts continence; three C's (poor in all three) predicts incontinence. ↗
▶ Ep 90 · 43:10
clinical A bulbar fistula with sacral ratio of 1 and normal spine should absolutely have bowel control. ↗
▶ Ep 90 · 43:25
clinical A bladder neck fistula with poor sacrum (sacral ratio 0.4) and tethered cord or myelomeningocele has no real chance of good bowel control. ↗
▶ Ep 90 · 43:45
clinical For four-year-olds with soiling, Levitt's first step is mechanical bowel management with enemas to achieve cleanliness, then trial laxatives when older/more mature for those with continence potential. ↗
▶ Ep 90 · 44:20
clinical If patients cannot be weaned off enemas, an antegrade option like Malone can be discussed. ↗
▶ Ep 90 · 44:35
clinical Redo pull-through is indicated for patients with any continence potential who have improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula (posterior urethral diverticulum). ↗
▶ Ep 90 · 45:10
clinical Redoing an anoplasty to center the rectum in the sphincter can change a patient to have potential for bowel control. ↗
▶ Ep 90 · 46:05
opinion One of the biggest problems with ARM is that if you don't get it right, you don't know for a few years, unlike most surgical complications which are immediately apparent. ↗
▶ Ep 90 · 46:40
opinion Surgeons cannot learn to fix their technique when problems only become obvious years later (e.g., soiling at age four), which is why there is so much morbidity in colorectal surgery. ↗
▶ Ep 90 · 46:50
quote How are you supposed to, as a surgeon, know what to fix about your technique if your problems are only becoming obvious years later? ↗

Anorectal Malformations Complications

▶ Ep 91 · 2:55
quote You'd be surprised how common these malformations are not properly diagnosed or completely missed in the newborn period. ↗
▶ Ep 91 · 2:55
epidemiological Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period. ↗
▶ Ep 91 · 3:05
clinical Male infants with perineal fistula may pass meconium and present in the first year of life with severe constipation when the fistula is missed. ↗
▶ Ep 91 · 3:25
clinical In missed perineal fistula, the rectum and sigmoid dilate because stool passes through a very tiny fistulous orifice which is not normal anal or rectal mucosa. ↗
▶ Ep 91 · 4:00
clinical Missed anorectal malformation can lead to perforation if stool doesn't pass satisfactorily. ↗
▶ Ep 91 · 4:20
quote Nowadays, the standard is to not even check a rectal temperature, is to check a temperature on the forehead or in the ear, and therefore, you don't have to look. If you don't look, you might not know. ↗
▶ Ep 91 · 4:20
clinical The current standard is to check temperature on forehead or ear rather than rectally, which means the anus may not be examined. ↗
▶ Ep 91 · 4:53
clinical Relocating perineal fistula into sphincters does not completely fix constipation, though it improves anatomy. ↗
▶ Ep 91 · 5:30
clinical Patients with uncorrected perineal fistula can have some continence with formed stool but will soil with loose stool or athletic activity because they cannot completely close the hole when squeezing sphincters. ↗
▶ Ep 91 · 6:15
clinical A newborn anus should accept a size 12 Hagar dilator, and a one-year-old should accept size 15. ↗
▶ Ep 91 · 6:25
clinical In perineal fistula, the anal opening is in the anterior portion of the pinkish ellipse (sphincter) or completely anterior to it. ↗
▶ Ep 91 · 6:41
clinical A bucket handle skin tag is consistent with perineal fistula; a probe can be passed underneath it, and the fistula lies beneath. ↗
▶ Ep 91 · 7:05
clinical Beads of meconium (black) or mucus (white) along the scrotal raphae are consistent with perineal fistula. ↗
▶ Ep 91 · 8:00
clinical Diagnostic criteria for female perineal fistula: hole too close to vagina (inadequate perineal body), inadequate hole size, and hole not centered in sphincter. ↗
▶ Ep 91 · 8:50
clinical If the anal hole is adequate size and centered in the sphincter, even if appearing slightly anterior with short perineal body, no surgery is needed; the perineal body will lengthen with growth. ↗
▶ Ep 91 · 9:05
quote One of my professors like to say it's very hard to improve on an asymptomatic patient. ↗
▶ Ep 91 · 9:51
clinical Examination under anesthesia with stimulation can confirm whether the anal opening is properly centered in the sphincter when diagnosis is uncertain. ↗
▶ Ep 91 · 11:00
clinical An anesthesia nerve stimulator ($150) with appropriate needle probes works as well as a dedicated Pena stimulator ($15,000). ↗
▶ Ep 91 · 12:38
epidemiological The vast majority of male ARM patients have rectourethral fistula. ↗
▶ Ep 91 · 12:48
clinical Rectourethral fistula should not be approached primarily because the rectum location is unknown; it could be at bladder neck, prostatic, or bulbar level. ↗
▶ Ep 91 · 13:10
clinical If posterior sagittal incision is made without knowing rectal location, a midline white shiny structure will be found that might be urinary tract, not rectum. ↗
▶ Ep 91 · 13:30
clinical With laparoscopy for rectourethral fistula, all cases go slightly below peritoneal reflection, making it impossible to distinguish bladder neck, prostatic, or bulbar fistula. ↗
▶ Ep 91 · 13:45
guideline Rectourethral fistula patients should receive colostomy with distal colostogram. ↗
▶ Ep 91 · 13:53
clinical Exceedingly rarely, a cross-table lateral film at 20 hours showing very low rectum may allow safe primary posterior sagittal approach. ↗
▶ Ep 91 · 14:04
clinical Cloaca can be missed in the newborn period; a recent case presented at six months with constipation. ↗
▶ Ep 91 · 14:40
quote I just think that we need to standardize our newborn exam. I think their lost art of examining the anus and ensuring that someone's putting a rectal thermometer in is an unfortunate change into modern medicine because I think it's harder to miss an anal rectal malformation if someone's put a probe through. ↗
▶ Ep 91 · 14:40
guideline Newborn examination should be standardized to include conscious visual inspection of the anus and confirmation of adequate size and location. ↗
▶ Ep 91 · 15:49
clinical Ambiguous genitalia with clitoromegaly and normal anus represents urogenital sinus with virilization, an endocrine problem. ↗
▶ Ep 91 · 16:15
clinical Cloaca patients have no anus, a urogenital sinus, large clitoris (not from endocrine stimulation), and two completely normal ovaries with no endocrine problem. ↗
▶ Ep 91 · 17:04
quote I think that operation of a colostomy needs to be taken very seriously, and every pediatric surgeon who deals with newborns, which is the art of our specialty, needs to be really, really good at this because there's a lot of morbidity that's conveyed to a patient with an improperly done colostomy. ↗
▶ Ep 91 · 17:20
clinical The most common colostomy error is opening too distal in the sigmoid, restricting the ultimate pull-through. ↗
▶ Ep 91 · 17:35
clinical Incompletely diverting loop colostomies allow stool to spill across and contaminate the distal segment, leading to urinary tract infections. ↗
▶ Ep 91 · 18:00
clinical Separated stomas prevent any chance of stool crossing to the distal segment. ↗
▶ Ep 91 · 18:20
clinical Transverse colostomies can prolapse and, with large rectourethral fistula, cause the left colon to absorb urine, leading to acidosis. ↗
▶ Ep 91 · 18:45
clinical Distal colostogram through transverse colostomy is difficult, requires high pressure, and leaves meconium in the entire distal segment for months. ↗
▶ Ep 91 · 19:10
guideline Proximal sigmoid colostomy leaves the entire sigmoid loop for pull-through and should be performed laparoscopically with separated stomas. ↗
▶ Ep 91 · 20:03
clinical Mid-transverse colostomy: both sides can prolapse. Hepatic flexure colostomy: only distal side prolapses. Proximal sigmoid colostomy: only distal (mucous fistula) can prolapse if not made tiny and flat. ↗
▶ Ep 91 · 20:40
clinical Ileostomies prolapse frequently because they are free-floating unless tacked to anterior abdominal wall. ↗
▶ Ep 91 · 21:20
clinical Anoplasty location should be marked on the skin surface before making any incision by drawing a circle around the pinkish ellipse where it stimulates. ↗
▶ Ep 91 · 21:50
quote I think what happens is if people don't do that, then they're open in, let's say, a posterior sagittal incision. And then they see a bunch of muscles jumping around with the stimulator and they choose the wrong place. ↗
▶ Ep 91 · 22:10
clinical Surgeons can choose the wrong anoplasty location when they see muscles jumping with stimulator after opening the incision, because they lack a reference landmark. ↗
▶ Ep 91 · 23:03
clinical Really good surgeons have put anuses in wrong locations because everything is disrupted once the incision is open and they lack a sense of center. ↗
▶ Ep 91 · 23:03
quote Really, really good surgeons have put anuses in crazy places. And I think it's because they don't have a sense of what's the center because everything's disrupted once it's open. ↗
▶ Ep 91 · 23:29
clinical Distal colostogram is an absolutely vital study; many mistakes result from poorly done studies and misinterpretation. ↗
▶ Ep 91 · 23:29
quote The distal colostagram is really an absolutely vital study. And a lot of mistakes are made because of a poorly done study, first of all, and then a misinterpretation of that study. ↗
▶ Ep 91 · 23:45
clinical The distal colostogram must answer: where is the rectum, how low is it, is it reachable posterior sagittally or better approached laparoscopically, and what is its relationship to the urinary tract. ↗
▶ Ep 91 · 24:15
clinical Common colostogram error: insufficient contrast and pressure, giving false impression that rectum is high or that there is no fistula. ↗
▶ Ep 91 · 24:35
clinical If the distal rectum shows a straight line flattening corresponding to the pubococcygeal line, the radiologist did not give enough contrast or pressure. ↗
▶ Ep 91 · 25:00
clinical The PC line is where the sphincters compress the distal rectum; more pressure is needed to overcome this and show the bulging rectum and fistula. ↗
▶ Ep 91 · 25:00
quote You need to overcome the PC line because that's the sphincters. That's where the sphincters are compressing the distal rectum. ↗
▶ Ep 91 · 25:25
clinical Rectourethral fistula can be at bladder neck, prostatic level, or bulbar level. The urethra looks like a reverse C or elbow: fistula at or below the elbow is bulbar; above the elbow is prostatic; at bladder neck is bladder neck fistula. ↗
▶ Ep 91 · 26:05
clinical Colostogram should show whether the rectum is bulbous or tapered. Bulbous rectum may be reachable posterior sagittally but hard laparoscopically due to girth. Tapered rectum is better approached laparoscopically. ↗
▶ Ep 91 · 27:00
clinical Opening posterior sagittal incision without knowing rectal location will reveal a whitish shiny midline structure that may be bladder neck, not rectum. ↗
▶ Ep 91 · 27:25
clinical Proper distal colostogram tells the surgeon exactly where to look for the rectum: right under the coccyx for prostatic fistula, distal to coccyx for bulbar, or not reachable posterior sagittally for bladder neck. ↗
▶ Ep 91 · 28:00
clinical Bulbous prostatic fistulas can be found right under the coccyx and are preferably done posterior sagittally. ↗
▶ Ep 91 · 28:15
clinical Bulbar fistulas are nearly at the perineal skin and should definitely be done posterior sagittally, not laparoscopically, because transabdominal approach requires more work. ↗
▶ Ep 91 · 29:05
clinical If uncertain whether a structure is rectum, place stitches on either side and open in midline; if wrong, close it. Staying perfectly midline allows safe closure if urinary tract is opened. ↗
▶ Ep 91 · 29:20
quote You should never go to the operating room without knowing exactly what anatomy you're going to expect to find. And the big question is, where is the rectum? Is it the most posterior structure? And where is it the most posterior structure? ↗
▶ Ep 91 · 29:30
guideline Never go to the operating room without knowing exactly what anatomy to expect. The key question is: where is the rectum and is it the most posterior structure? ↗
▶ Ep 91 · 30:10
guideline Bulbar or low prostatic fistula with bulging rectum: approach posterior sagittally. High prostatic with tapered rectum or bladder neck fistula: approach laparoscopically. ↗
▶ Ep 91 · 30:40
clinical Attempting laparoscopy for bulging rectum below peritoneal reflection (low prostatic or bulbar) requires unnecessary extra work and risks leaving behind a remnant of the original fistula (roof). ↗
▶ Ep 91 · 31:15
clinical Attempting posterior sagittal approach for high rectum is very difficult to mobilize and risks urinary tract injury. ↗
▶ Ep 91 · 31:45
clinical Laparoscopy replaces laparotomy, not PSARP. A mini-PSARP incision (3-4 cm) allows safe entry hugging the sacral hollow and permits rectal fixation to posterior muscle complex to prevent prolapse. ↗
▶ Ep 91 · 32:10
quote I don't see any advantage of that. There's really nothing that you're cutting if you make the incision a little bit bigger. It's much safer. ↗
▶ Ep 91 · 32:30
clinical Prolapse is very common if the rectum is not fixed; some hitch to pelvis, but Dr. Levitt prefers fixation to muscle complex through posterior sagittal incision. ↗
▶ Ep 91 · 32:40
quote I like to call mine a laparoscopic-assisted PSARP. I think that's a better terminology. ↗
▶ Ep 91 · 33:03
clinical Prolapse prevention: proper anoplasty location, adequate levator closure, posterior wall fixation to muscle complex (3-4 stitches), and minimal rectal dissection so rectum lands where anus should be without excessive trimming. ↗
▶ Ep 91 · 33:40
epidemiological Prolapse occurs in about 3% of cases, particularly in patients without great muscles. ↗
▶ Ep 91 · 34:00
clinical Rectal prolapse causes bleeding, mucus discharge, and in patients with good continence potential, inhibits bowel control because they cannot close the opening with prolapsed tissue through it. ↗
▶ Ep 91 · 34:30
clinical Dr. Levitt trims prolapse greater than about 3 millimeters. Ectropium versus prolapse distinction is not critical; both are extra reddish tissue, usually circumferential but can be unilateral. ↗
▶ Ep 91 · 34:55
clinical For circumferential prolapse, Dr. Levitt trims half the circumference in two different ambulatory settings, which families prefer to hospitalization and eliminates need for dilation because half the circumference is untouched. ↗
▶ Ep 91 · 35:45
epidemiological Perineal body dehiscence is the most common cause of reoperation Dr. Levitt performs. ↗
▶ Ep 91 · 35:55
clinical The key to preventing perineal body dehiscence is complete mobilization of anterior rectal wall from posterior vaginal wall, reaching the areolar plane between them. ↗
▶ Ep 91 · 36:15
clinical Inadequate anterior rectal wall mobilization leaves the anoplasty under tension, which can pull back, leak into perineal body space, and cause dehiscence. ↗
▶ Ep 91 · 36:35
clinical Perineal body closure should use 3-0 suture in a baby (secure closure) and 4-0 Vicryl on perineal skin. ↗
▶ Ep 91 · 36:50
clinical Dr. Levitt traditionally used 7-day NPO on 10% dextrose (Hyper-L only if longer than 7 days) but now trials clear liquids only for one week to prevent hard stool while allowing more stool volume. ↗
▶ Ep 91 · 37:15
quote The major problem was hard stool. We didn't want them to pass hard stool. And if you give a kid clear liquids, they won't make hard stool. They may make more stool, but they won't make hard stool. ↗
▶ Ep 91 · 37:25
clinical The major problem causing dehiscence is hard stool passing through the repair. Clear liquids prevent hard stool formation. ↗
▶ Ep 91 · 37:41
clinical Feeding regular diet in a day or two and sending the patient home without perineal monitoring risks dehiscence from hard stool passage. ↗
▶ Ep 91 · 37:55
clinical If perineal body dehiscence is detected on day 5-8, taking the patient back to OR for re-suturing can salvage the repair. This occurs in about 1-2 cases per 200. ↗
▶ Ep 91 · 37:55
quote If you see it's opening, I actually will take them back to the OR and re-suture the perineal body. You can actually save it by doing that. ↗
▶ Ep 91 · 38:17
clinical If dehiscence is not detected until 3-4 weeks later, the whole perineal body is dehisced and nothing can be done. ↗
▶ Ep 91 · 38:38
clinical Laparoscopy causes trouble when used to dissect a rectum that is too low, risking proximity to urinary tract or leaving behind remnant of original fistula from timidity. ↗
▶ Ep 91 · 39:05
clinical Blind trocar passage through small perineal incision is dangerous. A 3-4 cm posterior sagittal incision allows safer passage hugging the sacral hollow. ↗
▶ Ep 91 · 39:30
clinical For high rectums, especially bladder neck fistulas, distal rectal dissection is challenging to achieve adequate reach with good blood supply. ↗
▶ Ep 91 · 39:50
clinical The IMA must be preserved because prior colostomy disrupted left colic collaterals, making the rectum completely dependent on IMA. ↗
▶ Ep 91 · 40:05
clinical Tiny distal vessels along the rectal wall can be taken because the rectum has excellent intramural blood supply from the IMA. ↗
▶ Ep 91 · 40:17
clinical The biggest problem with posterior sagittal incision is opening without knowing where the rectum is, leading to finding bladder neck, urethra, seminal vesicles, vas deferens, ectopic ureter—everything but distal rectum. ↗
▶ Ep 91 · 40:20
clinical Taking the IMA or taking branches too close to the aorta will cause rectal necrosis because there is no collateralization down the left colic. ↗
▶ Ep 91 · 41:00
clinical There are famous cases of bladder neck being pulled through and made into anoplasty, with patients draining liquid (urine) postoperatively. ↗
▶ Ep 91 · 41:00
quote There are some famous cases of pull through bladder neck made into beautiful anoplasties. And post-op, the patient was draining liquid out their anoplasty. And in fact, it was the bladder neck. ↗
▶ Ep 91 · 42:15
clinical To assess continence potential in a four-year-old with soiling, Dr. Levitt evaluates three factors: original malformation type, sacral quality (sacral ratio), and spine quality. This is the ARM continence index. ↗
▶ Ep 91 · 42:40
quote I usually tell parents that I'll give you a grade in type of malformation, quality of sacrum, and quality of spine. And three A's is a continent patient. And three C's is an incontinent patient. ↗
▶ Ep 91 · 42:50
clinical Three A's (excellent malformation type, sacrum, and spine) predicts continence. Three C's predicts incontinence. The in-between grades are being studied. ↗
▶ Ep 91 · 43:15
clinical A bulbar fistula with sacral ratio of 1 and normal spine should absolutely have bowel control. ↗
▶ Ep 91 · 43:30
clinical A bladder neck fistula with poor sacrum (sacral ratio 0.4) and tethered cord or myelomeningocele has no real chance of good bowel control. ↗
▶ Ep 91 · 44:00
clinical For four-year-old with soiling, first step is mechanical cleanliness with bowel management using enemas, then trial of laxatives when older and more mature if continence potential exists. ↗
▶ Ep 91 · 44:30
clinical If patient cannot be weaned off enemas, an antegrade option like Malone can be discussed. ↗
▶ Ep 91 · 44:55
clinical Indications for redo pull-through: any continence potential with imperfect anatomy (improperly located anus, anal stricture, rectal prolapse, or remnant of original fistula/posterior urethral diverticulum). ↗
▶ Ep 91 · 45:25
clinical Redoing anoplasty to center the rectum in the sphincter can change a patient to have continence potential. ↗
▶ Ep 91 · 45:37
clinical If patient has absolutely no continence potential, they only need a hole through which to do enemas; redo is not indicated. ↗
▶ Ep 91 · 46:50
opinion ARM surgery is unique because errors may not become apparent for years, making it difficult for surgeons to learn from mistakes and improve technique. ↗
▶ Ep 91 · 47:00
quote Most things in surgery, if you don't do it right, you know right away. Like, if you don't sew a hepatic artery together properly during a liver transplant, the next day, you have a thrombosed artery. If you don't put an anus in the right place, you think you did a perfectly fine operation, the patient goes home, everyone's happy, and only four years later do they come soiling. ↗
▶ Ep 91 · 47:12
opinion In most surgery, errors are immediately apparent (e.g., thrombosed hepatic artery after liver transplant), but misplaced anus only becomes obvious years later when child presents with soiling. ↗
▶ Ep 91 · 47:40
quote How are you supposed to, as a surgeon, know what to fix about your technique if your problems are only becoming obvious years later? And I think that's why there is so much morbidity in colorectal. ↗
Appendicitis 100 entries

Hirschsprung Disease Part I with Marc Levitt

▶ Ep 4 · 8:43
clinical The best treatment for Hirschsprung disease is irrigations using a large bore tube (20 French Foley) with warm saline, instilling 10-20 cc aliquots at a time and allowing fluid mixed with stool to drain back. ↗
▶ Ep 4 · 8:55
clinical It is very rare that Hirschsprung disease is a surgical emergency, but if you don't irrigate and overcome the distal obstruction, it will become an emergency. ↗
▶ Ep 4 · 8:55
quote It is very rare that Hirschberg's disease is a surgical emergency. But if you don't irrigate and overcome the distal obstruction, it will become an emergency. ↗
▶ Ep 4 · 9:13
quote If you take a large bore tube, like a 20 French Foley, and get some warm saline irrigation, I take a 60 cc non-morlock syringe. And I basically um insert about 10 to 20 cc aloquats at a time, passing it with the lubricant, of course, instilling saline, moving the tube to and fro, advancing it as far as you can without needing resistance, and then you take the 60 cc syringe off the tube and let the fluid mixed with stool drip back. ↗
▶ Ep 4 · 11:02
quote Babies with Hirschberg's disease have no ability to expel the enema fluid. ↗
▶ Ep 4 · 12:38
clinical For rectal biopsy in suspected Hirschsprung disease, you must be at least 1 centimeter in from the dentate line. If you biopsy too close to the dentate line, everyone has an aganglionic segment there and you could get the wrong answer. ↗
▶ Ep 4 · 13:03
quote You have to be careful not to biopsy too high. If the gun gets sent in too, too deep and biopsies at 4 or 5 centimeters, which I have seen happen, you may miss a lower zone of Hirschberg's disease. ↗
▶ Ep 4 · 13:23
clinical The pathologist must report both the absence of ganglion cells AND the presence of hypertrophic nerves. The absence of ganglion cells alone is not Hirschsprung disease - that could be a biopsy taken too low. ↗
▶ Ep 4 · 13:23
quote The pathologist really needs to be prepared for evaluation of Hirschberg's disease, and you as the surgeon cannot accept a pathologist's report unless there is the absence of ganglion cells and the presence of hypertrophic nerves. The absence of ganglion cells alone is not Hirschberg's disease. ↗
▶ Ep 4 · 14:35
quote Interestingly, if you put a cork in a newborn baby and they didn't stool for one week. They would not get sick. They would just be distended and have hard stool. But Hirschprung's disease has an immune component to it, and the, the lining of the bowel, the mucosa, is much more susceptible to translocation. ↗
▶ Ep 4 · 14:59
clinical Hirschsprung disease has an immune component and the lining of the bowel (mucosa) is much more susceptible to bacterial translocation. Stasis in a Hirschsprung patient leads to bacterial translocation and a very sick baby from bacteremia. ↗
▶ Ep 4 · 15:42
clinical If irrigations are not working and the baby is ill, you need to divert. The recommendation is to divert in the ileum rather than doing a leveling colostomy, because frozen section can be inaccurate, particularly as you move higher in the colon. ↗
▶ Ep 4 · 18:14
clinical The Swenson operation involved full-thickness transabdominal dissection down below the peritoneal reflection. The operation was often done incorrectly with perirectal dissection done too wide, leading to fecal incontinence, urinary incontinence, sexual problems, and impotence. ↗
▶ Ep 4 · 19:28
clinical The Suave operation used a mucosal dissection to keep the outer rectal wall intact and avoid injury. The original Suave would leave the colon coming through the anus for a week before doing the coloanal anastomosis; Dr. Scott Boley modified it to do everything in one stage. ↗
▶ Ep 4 · 20:18
clinical The Duhamel operation leaves the original rectum in place, removes the aganglionic portion from the peritoneal reflection, and pulls ganglionic bowel in a retrorectal position, connecting the two lumens with a stapler. ↗
▶ Ep 4 · 21:18
quote It's fascinating actually that, you know, of those four procedures, the only one that actually leaves behind virtually no Hirschprungs is the Swenson. The suave leaves behind the outer rectal wall. The Duhamel leaves behind the original rectum, and the ravine leaves behind the original rectum as well. Amazingly, many, many of those patients did perfectly well, and I think that has to do with the fact that the ganglionic bowel, if it's good, can overcome a lot. ↗
▶ Ep 4 · 21:18
clinical Of the four classic procedures (Swenson, Suave, Duhamel, Rabine), only the Swenson actually leaves behind virtually no Hirschsprung tissue. The others leave behind outer rectal wall or original rectum. Many patients did well despite this because ganglionic bowel, if it's good, can overcome a lot. ↗
▶ Ep 4 · 22:19
clinical Dr. Henrys in the Philippines pioneered primary pull-through operations (without initial colostomy) out of necessity because patients would never return to clinic due to social stigma against colostomies. ↗
▶ Ep 4 · 23:21
clinical Keith Jorgeson applied laparoscopic skills to Hirschsprung disease, doing the colonic work laparoscopically with a Suave dissection from above. Luis de la Torre and Jack Langer developed the transanal approach, starting the dissection from below. ↗
▶ Ep 4 · 25:34
opinion The current preferred approach is a transanal Swenson (full-thickness dissection). It is the purest operation, leaving behind no Hirschsprung except the very bottom just above the dentate line. If you find the right plane, it's elegant and bloodless. ↗
▶ Ep 4 · 25:34
quote I have started to do about 10 years ago, I would say a transanal Swenson. So when you say Swenson, you have to remember that was transabdominal. When you say swab, that was transabdominal. So I think it's appropriate to say. Transanal suave-like or suave plain or transanal Swenson-like or Swenson plane, and I mean by that full thickness. ↗
▶ Ep 4 · 26:23
clinical Dr. Orvar Swenson, who recently died at age 105, maintained that the Swenson operation was good all along and people just weren't doing it right, which gave it a bad reputation. ↗
▶ Ep 4 · 26:23
quote Dr. Swenson himself, who recently died at the age of, I believe, 105, was a big fan of helping us, help reminding us of how good the Swenson was, because he said, you know, I've been saying the Swenson operation has been good all along. People just weren't doing it right, and it got a bad rap, unfortunately. ↗
▶ Ep 4 · 27:06
clinical Even Suave enthusiasts are making shorter and shorter cuffs over time. Jorgeson's original laparoscopic Suave recommended a 5 cm cuff; nowadays Langer and de la Torre do 1-1.5 cm cuffs, essentially approaching a Swenson. ↗
▶ Ep 4 · 28:50
opinion Laparoscopy is appropriate for all cases to find the transition zone level. A transanal-only approach is only appropriate when you have a very reachable, obvious transition zone at mid-sigmoid that you can comfortably reach transanally. ↗
▶ Ep 4 · 29:06
quote I have seen a lot of morbidity that has resulted from an overly aggressive transanal-only approach, um, trying to reach the transition zone with the, with the valiant attempt of never going into the abdomen laparoscopically or via laparotomy, and I think that that is a problem. ↗
▶ Ep 4 · 29:18
clinical There is significant morbidity from an overly aggressive transanal-only approach trying to reach the transition zone without going into the abdomen. If you're too aggressive transanally trying to visualize the dissection, you would have been better off with laparoscopic dissection. ↗
▶ Ep 4 · 31:18
clinical Total colonic Hirschsprung patients present differently: the diagnosis isn't made right away, the contrast study is not typical, and irrigations don't go well. These patients need laparoscopy first to find the biopsy location. ↗
▶ Ep 4 · 32:35
quote If you do a trans anal and you're too aggressive in your attempt to visualize the dissection. You would have been much better off with a lower laparoscopic dissection, no question about it. ↗
▶ Ep 4 · 33:55
quote The biggest problem is people don't give themselves good exposure and then they start the dissection too low and they injure the dentate line or resect the dentate line. Or they give themselves very aggressive exposure and they overstretch the sphincters. ↗
▶ Ep 4 · 34:09
clinical The biggest technical problems are: (1) surgeons don't give themselves good exposure and start dissection too low, injuring or resecting the dentate line, or (2) they give very aggressive exposure and overstretch the sphincters. ↗
▶ Ep 4 · 35:30
clinical Proper technique requires marking 1 cm proximal to the dentate line with a purple mark and placing 5-0 silk stitches circumferentially at that level. This preserves the anal canal, dentate line, plus an additional 1 cm of columnar epithelium before starting dissection. ↗
▶ Ep 4 · 36:39
quote By definition, you're leaving behind 1 centimeter of columnar epithelium, that of course is Hirschberg's disease, but the ganglionic bowel is able to overcome that. And of course you're leaving behind the smooth muscle, the internal sphincter, which has a problem by definition with relaxation. However, that can be overcome by good ganglionated bowel pushing through and eventually the baby recognizing how to relax that sphincter over time. ↗
▶ Ep 4 · 36:39
clinical By definition, you're leaving behind 1 cm of columnar epithelium that is Hirschsprung disease, plus the internal sphincter which has a problem with relaxation. However, good ganglionic bowel is able to overcome that, and the baby eventually learns to relax the sphincter. ↗
▶ Ep 4 · 38:19
clinical The rectum doesn't really have a mesentery; the rectum's blood supply is intramural. As you get higher and reach the peritoneal reflection, that's when you start to see sigmoidal vessels where rectum transitions to sigmoid. ↗
▶ Ep 4 · 38:19
quote The rectum doesn't really have a mesentery. The rectum's blood supply is intramural. ↗
▶ Ep 4 · 38:45
clinical The anterior rectum frees up much quicker than the posterior rectum. Break into the peritoneal reflection anteriorly first. In transanal-only cases, you can pull the sigmoid out anteriorly, do a full-thickness biopsy, and send it while continuing the posterior dissection. ↗
▶ Ep 4 · 40:56
clinical For laparoscopic biopsies through the umbilicus, a seromuscular biopsy (without violating mucosa) may show ganglion cells in the seromuscular layer but miss hypertrophic nerves in the submucosa. If using this technique, send a full-thickness biopsy later to confirm the level is appropriate. ↗
▶ Ep 4 · 44:03
clinical Pathologists must report not only ganglion cells but also the quality of nerves with actual micron measurements. Nerves should be 40 microns or less. Anything bigger than 40 microns is transition zone bowel. ↗
▶ Ep 4 · 44:20
clinical The concept of 'go 5 cm above the transition zone' is inaccurate. Transition zone is a spectrum - some are 10 cm, some are 3 cm. You need confirmatory biopsy with ganglion cell information and nerve quality measured in microns. ↗
▶ Ep 4 · 44:20
quote The concept of go 5 centimeters above, and I think that's inaccurate. I think transition zone is a spectrum. I've seen 10 centimeter transition zone. I've seen 3 centimeter transition zones. So you really need a confirmatory biopsy, and your pathologist can. If properly trained, gets you the ganglion cell information and also the quality of the nerves to the to the micron measurement. ↗
▶ Ep 4 · 45:57
clinical It's preferable to take the IMA, preserve the arcade, and have the left colon and sigmoid nice and straight down into the perineum. This makes for an easy-to-irrigate baby. Many patients have not had enough of a pull-through with the entire sigmoid loop still there, requiring redo to remove more. ↗
▶ Ep 4 · 47:02
clinical For anything proximal to the splenic flexure, do colonic biopsies and an ileostomy and wait, because frozen section has been notoriously fraught with errors in those cases. There is no urgency. Another option is to take biopsies, quit without diverting, and return 3-4 days later for pull-through with permanent section results. ↗
▶ Ep 4 · 53:16
quote I am passionately committed to not have a baby come back. And readmitted with enterocolitis, and I, what I will do is I will wait until the belly is absolutely soft and flat. They're having bowel function, passing gas, stooling. I actually will get an X-ray because I think abdominal distention is sometimes subclinical, and I don't feed that baby until the X-ray looks good and the belly's flat, and that usually takes 3 or 4 days. ↗
▶ Ep 4 · 53:23
clinical Postoperatively, wait until the belly is absolutely soft and flat with bowel function before feeding. Get an X-ray because abdominal distention is sometimes subclinical. This usually takes 3-4 days. Feeding too early risks the baby going home distended and returning with enterocolitis. ↗
▶ Ep 4 · 54:39
clinical Routine postoperative management: at one month, check the anus with Hagar dilators (not finger). Most babies need calibration rather than true dilation. The stimulation of passing the Hagar has value to help the baby more successfully empty. ↗
▶ Ep 4 · 55:52
clinical Flagyl is only used to treat enterocolitis, not routinely postoperatively. Give a pre-op dose of second-generation cephalosporin and maybe 2 post-op doses. ↗
▶ Ep 4 · 56:31
clinical Routine irrigations are only done postoperatively if the baby develops significant distention, which is rare. However, for total colonic patients after ileoanal pull-through, send all patients home on irrigations for 3 months. ↗
▶ Ep 4 · 57:05
clinical For hepatic flexure transition zone (rare), open the patient rather than laparoscopy. Take down the entire right colon, recognize the ileocolic vessel and how it feeds the vessel paralleling the right colon. Often need to take the right colic artery. De-rotate the colon so cecum is at the hepatic liver bed, then do pull-through down the right side of abdomen. ↗
▶ Ep 4 · 58:02
clinical If bringing de-rotated colon down the left side of abdomen, must mobilize the ligament of Treitz so the mesenteric vessel is not draped across the third portion of duodenum, which can cause duodenal obstruction. ↗

Hirschsprung Disease Part I with Marc Levitt

▶ Ep 7 · 8:43
clinical The best treatment for Hirschsprung disease is irrigations using a large bore tube (20 French Foley) with warm saline, instilling 10-20 cc aliquots at a time and allowing fluid mixed with stool to drain back. ↗
▶ Ep 7 · 8:55
clinical It is very rare that Hirschsprung disease is a surgical emergency, but if you don't irrigate and overcome the distal obstruction, it will become an emergency. ↗
▶ Ep 7 · 8:55
quote It is very rare that Hirschberg's disease is a surgical emergency. But if you don't irrigate and overcome the distal obstruction, it will become an emergency. ↗
▶ Ep 7 · 9:13
quote If you take a large bore tube, like a 20 French Foley, and get some warm saline irrigation, I take a 60 cc non-morlock syringe. And I basically um insert about 10 to 20 cc aloquats at a time, passing it with the lubricant, of course, instilling saline, moving the tube to and fro, advancing it as far as you can without needing resistance, and then you take the 60 cc syringe off the tube and let the fluid mixed with stool drip back. ↗
▶ Ep 7 · 11:02
quote Babies with Hirschberg's disease have no ability to expel the enema fluid. ↗
▶ Ep 7 · 12:38
clinical For rectal biopsy in suspected Hirschsprung disease, you must be at least 1 centimeter in from the dentate line. If you biopsy too close to the dentate line, everyone has an aganglionic segment there and you could get the wrong answer. ↗
▶ Ep 7 · 13:03
quote You have to be careful not to biopsy too high. If the gun gets sent in too, too deep and biopsies at 4 or 5 centimeters, which I have seen happen, you may miss a lower zone of Hirschberg's disease. ↗
▶ Ep 7 · 13:23
clinical The pathologist must report both the absence of ganglion cells AND the presence of hypertrophic nerves. The absence of ganglion cells alone is not Hirschsprung disease - that could be a biopsy taken too low. ↗
▶ Ep 7 · 13:23
quote The pathologist really needs to be prepared for evaluation of Hirschberg's disease, and you as the surgeon cannot accept a pathologist's report unless there is the absence of ganglion cells and the presence of hypertrophic nerves. The absence of ganglion cells alone is not Hirschberg's disease. ↗
▶ Ep 7 · 14:35
quote Interestingly, if you put a cork in a newborn baby and they didn't stool for one week. They would not get sick. They would just be distended and have hard stool. But Hirschprung's disease has an immune component to it, and the, the lining of the bowel, the mucosa, is much more susceptible to translocation. ↗
▶ Ep 7 · 14:59
clinical Hirschsprung disease has an immune component and the lining of the bowel (mucosa) is much more susceptible to bacterial translocation. Stasis in a Hirschsprung patient leads to bacterial translocation and a very sick baby from bacteremia. ↗
▶ Ep 7 · 15:42
clinical If irrigations are not working and the baby is ill, you need to divert. The recommendation is to divert in the ileum rather than doing a leveling colostomy, because frozen section can be inaccurate, particularly as you move higher in the colon. ↗
▶ Ep 7 · 18:14
clinical The Swenson operation involved full-thickness transabdominal dissection down below the peritoneal reflection. The operation was often done incorrectly with perirectal dissection done too wide, leading to fecal incontinence, urinary incontinence, sexual problems, and impotence. ↗
▶ Ep 7 · 19:28
clinical The Suave operation used a mucosal dissection to keep the outer rectal wall intact and avoid injury. The original Suave would leave the colon coming through the anus for a week before doing the coloanal anastomosis; Dr. Scott Boley modified it to do everything in one stage. ↗
▶ Ep 7 · 20:18
clinical The Duhamel operation leaves the original rectum in place, removes the aganglionic portion from the peritoneal reflection, and pulls ganglionic bowel in a retrorectal position, connecting the two lumens with a stapler. ↗
▶ Ep 7 · 21:18
quote It's fascinating actually that, you know, of those four procedures, the only one that actually leaves behind virtually no Hirschprungs is the Swenson. The suave leaves behind the outer rectal wall. The Duhamel leaves behind the original rectum, and the ravine leaves behind the original rectum as well. Amazingly, many, many of those patients did perfectly well, and I think that has to do with the fact that the ganglionic bowel, if it's good, can overcome a lot. ↗
▶ Ep 7 · 21:18
clinical Of the four classic procedures (Swenson, Suave, Duhamel, Rabine), only the Swenson actually leaves behind virtually no Hirschsprung tissue. The others leave behind outer rectal wall or original rectum. Many patients did well despite this because ganglionic bowel, if it's good, can overcome a lot. ↗
▶ Ep 7 · 22:19
clinical Dr. Henrys in the Philippines pioneered primary pull-through operations (without initial colostomy) out of necessity because patients would never return to clinic due to social stigma against colostomies. ↗
▶ Ep 7 · 23:21
clinical Keith Jorgeson applied laparoscopic skills to Hirschsprung disease, doing the colonic work laparoscopically with a Suave dissection from above. Luis de la Torre and Jack Langer developed the transanal approach, starting the dissection from below. ↗
▶ Ep 7 · 25:34
quote I have started to do about 10 years ago, I would say a transanal Swenson. So when you say Swenson, you have to remember that was transabdominal. When you say swab, that was transabdominal. So I think it's appropriate to say. Transanal suave-like or suave plain or transanal Swenson-like or Swenson plane, and I mean by that full thickness. ↗
▶ Ep 7 · 25:34
opinion The current preferred approach is a transanal Swenson (full-thickness dissection). It is the purest operation, leaving behind no Hirschsprung except the very bottom just above the dentate line. If you find the right plane, it's elegant and bloodless. ↗
▶ Ep 7 · 26:23
clinical Dr. Orvar Swenson, who recently died at age 105, maintained that the Swenson operation was good all along and people just weren't doing it right, which gave it a bad reputation. ↗
▶ Ep 7 · 26:23
quote Dr. Swenson himself, who recently died at the age of, I believe, 105, was a big fan of helping us, help reminding us of how good the Swenson was, because he said, you know, I've been saying the Swenson operation has been good all along. People just weren't doing it right, and it got a bad rap, unfortunately. ↗
▶ Ep 7 · 27:06
clinical Even Suave enthusiasts are making shorter and shorter cuffs over time. Jorgeson's original laparoscopic Suave recommended a 5 cm cuff; nowadays Langer and de la Torre do 1-1.5 cm cuffs, essentially approaching a Swenson. ↗
▶ Ep 7 · 28:50
opinion Laparoscopy is appropriate for all cases to find the transition zone level. A transanal-only approach is only appropriate when you have a very reachable, obvious transition zone at mid-sigmoid that you can comfortably reach transanally. ↗
▶ Ep 7 · 29:06
quote I have seen a lot of morbidity that has resulted from an overly aggressive transanal-only approach, um, trying to reach the transition zone with the, with the valiant attempt of never going into the abdomen laparoscopically or via laparotomy, and I think that that is a problem. ↗
▶ Ep 7 · 29:18
clinical There is significant morbidity from an overly aggressive transanal-only approach trying to reach the transition zone without going into the abdomen. If you're too aggressive transanally trying to visualize the dissection, you would have been better off with laparoscopic dissection. ↗
▶ Ep 7 · 31:18
clinical Total colonic Hirschsprung patients present differently: the diagnosis isn't made right away, the contrast study is not typical, and irrigations don't go well. These patients need laparoscopy first to find the biopsy location. ↗
▶ Ep 7 · 32:35
quote If you do a trans anal and you're too aggressive in your attempt to visualize the dissection. You would have been much better off with a lower laparoscopic dissection, no question about it. ↗
▶ Ep 7 · 33:55
quote The biggest problem is people don't give themselves good exposure and then they start the dissection too low and they injure the dentate line or resect the dentate line. Or they give themselves very aggressive exposure and they overstretch the sphincters. ↗
▶ Ep 7 · 34:09
clinical The biggest technical problems are: (1) surgeons don't give themselves good exposure and start dissection too low, injuring or resecting the dentate line, or (2) they give very aggressive exposure and overstretch the sphincters. ↗
▶ Ep 7 · 35:30
clinical Proper technique requires marking 1 cm proximal to the dentate line with a purple mark and placing 5-0 silk stitches circumferentially at that level. This preserves the anal canal, dentate line, plus an additional 1 cm of columnar epithelium before starting dissection. ↗
▶ Ep 7 · 36:39
quote By definition, you're leaving behind 1 centimeter of columnar epithelium, that of course is Hirschberg's disease, but the ganglionic bowel is able to overcome that. And of course you're leaving behind the smooth muscle, the internal sphincter, which has a problem by definition with relaxation. However, that can be overcome by good ganglionated bowel pushing through and eventually the baby recognizing how to relax that sphincter over time. ↗
▶ Ep 7 · 36:39
clinical By definition, you're leaving behind 1 cm of columnar epithelium that is Hirschsprung disease, plus the internal sphincter which has a problem with relaxation. However, good ganglionic bowel is able to overcome that, and the baby eventually learns to relax the sphincter. ↗
▶ Ep 7 · 38:19
quote The rectum doesn't really have a mesentery. The rectum's blood supply is intramural. ↗
▶ Ep 7 · 38:19
clinical The rectum doesn't really have a mesentery; the rectum's blood supply is intramural. As you get higher and reach the peritoneal reflection, that's when you start to see sigmoidal vessels where rectum transitions to sigmoid. ↗
▶ Ep 7 · 38:45
clinical The anterior rectum frees up much quicker than the posterior rectum. Break into the peritoneal reflection anteriorly first. In transanal-only cases, you can pull the sigmoid out anteriorly, do a full-thickness biopsy, and send it while continuing the posterior dissection. ↗
▶ Ep 7 · 40:56
clinical For laparoscopic biopsies through the umbilicus, a seromuscular biopsy (without violating mucosa) may show ganglion cells in the seromuscular layer but miss hypertrophic nerves in the submucosa. If using this technique, send a full-thickness biopsy later to confirm the level is appropriate. ↗
▶ Ep 7 · 44:03
clinical Pathologists must report not only ganglion cells but also the quality of nerves with actual micron measurements. Nerves should be 40 microns or less. Anything bigger than 40 microns is transition zone bowel. ↗
▶ Ep 7 · 44:20
clinical The concept of 'go 5 cm above the transition zone' is inaccurate. Transition zone is a spectrum - some are 10 cm, some are 3 cm. You need confirmatory biopsy with ganglion cell information and nerve quality measured in microns. ↗
▶ Ep 7 · 44:20
quote The concept of go 5 centimeters above, and I think that's inaccurate. I think transition zone is a spectrum. I've seen 10 centimeter transition zone. I've seen 3 centimeter transition zones. So you really need a confirmatory biopsy, and your pathologist can. If properly trained, gets you the ganglion cell information and also the quality of the nerves to the to the micron measurement. ↗
▶ Ep 7 · 45:57
clinical It's preferable to take the IMA, preserve the arcade, and have the left colon and sigmoid nice and straight down into the perineum. This makes for an easy-to-irrigate baby. Many patients have not had enough of a pull-through with the entire sigmoid loop still there, requiring redo to remove more. ↗
▶ Ep 7 · 47:02
clinical For anything proximal to the splenic flexure, do colonic biopsies and an ileostomy and wait, because frozen section has been notoriously fraught with errors in those cases. There is no urgency. Another option is to take biopsies, quit without diverting, and return 3-4 days later for pull-through with permanent section results. ↗
▶ Ep 7 · 53:16
quote I am passionately committed to not have a baby come back. And readmitted with enterocolitis, and I, what I will do is I will wait until the belly is absolutely soft and flat. They're having bowel function, passing gas, stooling. I actually will get an X-ray because I think abdominal distention is sometimes subclinical, and I don't feed that baby until the X-ray looks good and the belly's flat, and that usually takes 3 or 4 days. ↗
▶ Ep 7 · 53:23
clinical Postoperatively, wait until the belly is absolutely soft and flat with bowel function before feeding. Get an X-ray because abdominal distention is sometimes subclinical. This usually takes 3-4 days. Feeding too early risks the baby going home distended and returning with enterocolitis. ↗
▶ Ep 7 · 54:39
clinical Routine postoperative management: at one month, check the anus with Hagar dilators (not finger). Most babies need calibration rather than true dilation. The stimulation of passing the Hagar has value to help the baby more successfully empty. ↗
▶ Ep 7 · 55:52
clinical Flagyl is only used to treat enterocolitis, not routinely postoperatively. Give a pre-op dose of second-generation cephalosporin and maybe 2 post-op doses. ↗
▶ Ep 7 · 56:31
clinical Routine irrigations are only done postoperatively if the baby develops significant distention, which is rare. However, for total colonic patients after ileoanal pull-through, send all patients home on irrigations for 3 months. ↗
▶ Ep 7 · 57:05
clinical For hepatic flexure transition zone (rare), open the patient rather than laparoscopy. Take down the entire right colon, recognize the ileocolic vessel and how it feeds the vessel paralleling the right colon. Often need to take the right colic artery. De-rotate the colon so cecum is at the hepatic liver bed, then do pull-through down the right side of abdomen. ↗
▶ Ep 7 · 58:02
clinical If bringing de-rotated colon down the left side of abdomen, must mobilize the ligament of Treitz so the mesenteric vessel is not draped across the third portion of duodenum, which can cause duodenal obstruction. ↗
Cloaca 278 entries

Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison

▶ Ep 8 · 2:38
clinical The most common prenatal ultrasound finding in cloaca is a pelvic mass, often initially thought to be the bladder but actually representing a dilated vagina (hydrocolpos). ↗
▶ Ep 8 · 3:59
clinical Fetal intervention for cloaca is unlikely but may be necessary for massive hydronephrosis with impending renal loss; one case report from Japan described hydrocolpos drainage similar to bladder drainage for urethral valves. ↗
▶ Ep 8 · 6:35
clinical In newborn examination, cloaca presents as one hole below the clitoris with no anus; this is distinct from urogenital sinus which has one hole but a normal anus. ↗
▶ Ep 8 · 7:25
clinical Cloaca is not ambiguous genitalia and has no adrenal problem; the baby is a normal female with two normal ovaries and will be hormonally normal. ↗
▶ Ep 8 · 9:03
clinical Many patients considered cloacas are actually vestibular fistulas; with better examination pulling the labia up and out, you can see three distinct holes (urethra, vagina, and vestibular fistula). ↗
▶ Ep 8 · 9:14
quote Mother Nature hates our distinctions, so she puts things in the middle of the vestibular and cloaca that there's a little bit of depth to the cloaca, but the urethra is sort of visible. ↗
▶ Ep 8 · 9:59
guideline Initial workup includes ultrasound for hydronephrosis and kidney number, spinal ultrasound for tethered cord, plain X-ray of spine for hemivertebrae and sacral quality, and echocardiogram at most centers. ↗
▶ Ep 8 · 13:27
clinical For bilateral hydrocolpos, open into both vaginas at the dome, remove some of the common wall (septum), and one tube will drain both sides. ↗
▶ Ep 8 · 14:15
clinical For vaginostomy tube placement, use an 8 or 10 French pigtail catheter from interventional radiology; a curled catheter prevents tube fallout as the hydrocolpos recedes, unlike straight catheters which fall out. ↗
▶ Ep 8 · 15:02
clinical Vesicostomy is rarely needed in cloaca because the problem is not the bladder but the hydrocolpos compressing the trigone and distal ureters; draining the hydrocolpos relieves the obstruction. ↗
▶ Ep 8 · 16:28
clinical Vesicostomy or suprapubic tube is indicated only when the common channel is very narrow or absent, preventing bladder drainage even after hydrocolpos decompression. ↗
▶ Ep 8 · 17:54
clinical Massive bilateral ureteral reflux is an exception where vesicostomy may be needed to decompress the system until later in life. ↗
▶ Ep 8 · 18:24
clinical Hydrocolpos forms because the bladder preferentially fills the vagina through a fistula rather than exiting the common channel; the vagina also contains mucus, and maternal estrogen can increase mucus production. ↗
▶ Ep 8 · 19:31
clinical The urethra in cloaca often requires a steep turn (scope on floor pointing to ceiling) to reach the bladder, explaining why urine does not drain easily and instead fills the vagina. ↗
▶ Ep 8 · 20:29
clinical Cystoscopy is not performed in the newborn period; it is delayed until 2-3 months when a larger scope can be used, visualization is better, and the baby is healthier. ↗
▶ Ep 8 · 22:27
clinical Urogenital sinus (one hole with normal anus) requires workup for adrenal problems and virilization; if virilized, likely has adrenal hyperplasia requiring electrolyte monitoring. ↗
▶ Ep 8 · 24:07
clinical Cloacal repair timing is typically 2-3 months for diagnostic endoscopy and cloacogram, with definitive repair anytime thereafter within the first year; Dr. Levitt aims for before 6 months if managing from birth, before 1 year if referred. ↗
▶ Ep 8 · 25:25
clinical The two critical endoscopic measurements are common channel length (traditional measure, with 3 cm or less being straightforward) and urethral length from urethral takeoff to bladder neck (newly emphasized measure that determines surgical approach). ↗
▶ Ep 8 · 26:21
clinical Endoscopy can falsely suggest the rectum is reachable when it is actually a long narrow fistula with healthy rectum in the abdomen; a contrast study (cloacogram) is needed to determine this. ↗
▶ Ep 8 · 27:24
clinical The cloacogram technique involves leaving catheters in the bladder, distal colostomy, and perineal orifice during endoscopy, then having interventional radiology inject these structures and create a 3D reconstruction. ↗
▶ Ep 8 · 28:34
clinical Studies comparing 2D cloacogram, 3D reconstruction, 3D printed models, and virtual reality showed that more complex modalities led to more correct anatomic descriptions; 3D is definitely better than 2D. ↗
▶ Ep 8 · 30:44
quote I think the days of a single surgeon being able to handle a case of this complexity are over. I am so thankful that I have urologists to help me and gynecologists to help me through these coal repairs. ↗
▶ Ep 8 · 32:15
clinical Urogenital mobilization, first described by Alberto Pena in 1996, mobilizes the urethra and vagina as a unit without operating on the wall between them, eliminating the 10% urethral-vaginal fistula rate from prior techniques. ↗
▶ Ep 8 · 32:33
quote I still remember that I was a trainee standing behind Alberto Pena as he explained to Hardy Hendren this concept, this new concept he had. Oh, you're a general scientist and immobilization. He was drawing pictures. I remember like it was yesterday. It was a moment of history. ↗
▶ Ep 8 · 33:39
clinical Urogenital mobilization is appropriate when common channel is 3 cm or less AND there is at least 1.5-2 cm of urethra above the urethral takeoff; this leaves adequate urethral length after splitting the common channel. ↗
▶ Ep 8 · 34:34
clinical When urethral length is inadequate (less than 1.5 cm from takeoff to bladder neck), the common channel must be left alone to become the urethra, and the vagina must be separated from the common channel—a technically demanding operation. ↗
▶ Ep 8 · 35:17
clinical If urogenital mobilization is attempted with inadequate urethral length and the complex does not reach, the only option is abdominal delivery of the urogenital complex, which often does not work and can lead to urethral devascularization and loss. ↗
▶ Ep 8 · 35:52
clinical Leaving a patient with inadequate urethral length after urogenital mobilization results in leakage with no way to gain control without tightening or closing the bladder neck. ↗
▶ Ep 8 · 36:05
clinical Separating the vagina from the common channel and leaving the common channel as the entire urethra gives the patient about a 4 cm urethra, allowing intermittent catheterization and continence. ↗
▶ Ep 8 · 36:40
clinical For type 1 cloaca (common channel of 1 cm with adequate urethral length), mobilizing the vagina alone and leaving a slightly hypospadiac urethra is acceptable if the patient will void and not require intermittent catheterization. ↗
▶ Ep 8 · 37:11
clinical Many cloaca patients have neurogenic bladder component whether or not they have tethered cord; a visible urethral orifice that is easily catheterized is needed if intermittent catheterization will be required. ↗
▶ Ep 8 · 38:00
clinical When native vagina does not reach after full mobilization, options include vaginal switch (disconnecting one side while preserving ovarian blood supply) or vaginal replacement with colon (preferred), small bowel, or rectum. ↗
▶ Ep 8 · 39:17
opinion Tissue engineering of vaginas using patient stem cells is on the horizon, with work done at Wake Forest and in Mexico; this could revolutionize cloaca care by eliminating the need for vaginal replacement. ↗
▶ Ep 8 · 40:27
clinical The most common problem in redo cloaca surgery is that the surgeon never realized they were dealing with a cloaca and only fixed the rectum, leaving the urogenital sinus untouched. ↗
▶ Ep 8 · 40:58
clinical The second most common redo problem is inadequate mobilization of structures, leaving the patient with a stenosed or lost vagina. ↗

Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison

▶ Ep 11 · 2:38
clinical The most common prenatal ultrasound finding in cloaca is a pelvic mass, often representing a dilated vagina (hydrocolpos). ↗
▶ Ep 11 · 3:56
clinical Fetal intervention for cloaca is unlikely to be necessary; babies should typically go to term. ↗
▶ Ep 11 · 5:14
clinical Fetal hydrocolpos drainage has been performed at least once (case report from Japan) for massive hydronephrosis with impending renal loss, similar to bladder drainage for urethral valves. ↗
▶ Ep 11 · 6:37
clinical In cloaca, there is one perineal hole below the clitoris and no anus; this is not ambiguous genitalia, there is no adrenal problem, and the baby is a normal female with two normal ovaries. ↗
▶ Ep 11 · 6:57
clinical A urogenital sinus (single hole with normal anus present) may be associated with virilization and requires evaluation for adrenal hyperplasia and electrolyte abnormalities. ↗
▶ Ep 11 · 8:36
clinical To examine a newborn for cloaca, grab the labia and lift them up and out with very good lighting to see if there is a single hole or distinct urethral, vaginal, and rectal orifices. ↗
▶ Ep 11 · 9:03
clinical Many patients considered cloacas actually have vestibular fistulas; with better examination you can see three holes (urethra, vagina, and rectal opening in vestibule). ↗
▶ Ep 11 · 9:59
clinical Initial workup for cloaca includes ultrasound for hydronephrosis and kidney number, spinal ultrasound for tethered cord, cardiac auscultation, and plain X-ray of spine to assess sacrum. ↗
▶ Ep 11 · 11:14
clinical Intermittent catheterization of the common channel may decompress hydrocolpos, but is not reliable because the catheter may enter the urethra, right or left vagina, or rectum; success should be confirmed by ultrasound. ↗
▶ Ep 11 · 13:14
clinical If hydrocolpos is bilateral, open into both vaginas at the dome, remove some of the common wall (septum), and one tube will drain both sides. ↗
▶ Ep 11 · 14:15
clinical For vaginostomy, use an 8 or 10 French pigtail catheter (not a straight catheter) because as hydrocolpos recedes, straight catheters fall out but curled catheters do not. ↗
▶ Ep 11 · 15:05
clinical Vesicostomy is rarely needed in cloaca; the problem is usually hydrocolpos compressing the trigone and distal ureters, not bladder drainage. Draining the hydrocolpos relieves the ureteral obstruction. ↗
▶ Ep 11 · 16:28
clinical Vesicostomy is indicated only when the bladder does not drain after successful hydrocolpos decompression, which occurs in very rare circumstances with very long narrow common channels or absent urethra. ↗
▶ Ep 11 · 17:54
clinical Vesicostomy is also indicated in the rare circumstance of massive bilateral ureteral reflux, where decompressing the system protects the ureters until later repair. ↗
▶ Ep 11 · 18:21
clinical Hydrocolpos develops because urine preferentially fills the vagina through the vaginal fistula rather than exiting the common channel, likely due to mechanical factors (steep urethral angle). ↗
▶ Ep 11 · 18:48
clinical Hydrocolpos fluid is typically a turbid combination of mucus and urine; maternal estrogen effect can increase mucus production and rarely cause blood in the hydrocolpos. ↗
▶ Ep 11 · 20:11
clinical Hydronephrosis in cloaca is caused by hydrocolpos pressing forward on the trigone and compressing the distal ureters where they enter the bladder. ↗
▶ Ep 11 · 20:29
opinion Cystoscopy in the newborn period is not advantageous; the required scope is tiny, visualization is poor, the perineum is swollen, and it is better to minimize OR time in newborns. ↗
▶ Ep 11 · 20:49
clinical Laparoscopic approach to colostomy and hydrocolpos drainage (described by Michigan group) provides excellent visualization and is a valuable technique. ↗
▶ Ep 11 · 21:17
clinical For massive hydrocolpos extending above the umbilicus, use a lower midline incision to access the dome, and consider a tubeless vaginostomy sutured to the abdominal wall like a G-tube. ↗
▶ Ep 11 · 22:28
clinical Urogenital sinus (single perineal opening with normal anus) requires workup for adrenal problems causing virilization, though it can occur without virilization. ↗
▶ Ep 11 · 23:17
clinical Most urogenital sinuses can be managed with perineal urogenital mobilization without touching the rectum; high UG sinus cases may require a transrectal (Astra) approach. ↗
▶ Ep 11 · 23:57
clinical Definitive cloaca repair timing: perform endoscopy and cloacography at 2–3 months of age, then repair anytime thereafter within one year, ideally before 6 months if managing from birth. ↗
▶ Ep 11 · 25:25
clinical The two critical endoscopic measurements are common channel length (from perineum to urethral takeoff) and urethral length (from urethral takeoff to bladder neck); urethral length determines the surgical approach. ↗
▶ Ep 11 · 25:27
clinical Traditional classification uses 3 cm common channel length (≤3 cm straightforward, >3 cm complicated), but urethral length is equally important and not mentioned in published papers. ↗
▶ Ep 11 · 26:06
quote You must leave the patient with an adequate length urethra. ↗
▶ Ep 11 · 26:21
clinical Endoscopy can falsely suggest the rectum is reachable when it is actually a long narrow fistula with healthy rectum high in the abdomen; contrast study (cloacogram) is needed to assess this. ↗
▶ Ep 11 · 28:34
clinical 3D cloacogram reconstruction is superior to 2D fluoroscopy; experienced surgeons answer anatomy questions more correctly with 3D imaging, and printed 3D models may be even better. ↗
▶ Ep 11 · 30:29
quote We like to joke that it's a Cloaca by committee. ↗
▶ Ep 11 · 30:29
opinion Cloaca patients benefit from collaborative multidisciplinary approach; the days of a single surgeon handling these cases alone are over. ↗
▶ Ep 11 · 30:38
quote I think the days of a single surgeon being able to handle a case of this complexity are over. ↗
▶ Ep 11 · 32:15
clinical Urogenital mobilization, first described by Alberto Pena in 1996, mobilizes urethra and vagina as a unit without operating on the wall between them, eliminating the 10% urethral-vaginal fistula rate of prior techniques. ↗
▶ Ep 11 · 32:33
quote I still remember that I was a trainee standing behind Alberto Pena as he explained to Hardy Hendren this concept, this new concept he had. Oh, you're a general scientist and immobilization. He was drawing pictures. I remember like it was yesterday. It was a moment of history. ↗
▶ Ep 11 · 33:39
clinical Urogenital mobilization is appropriate when common channel is ≤3 cm AND urethral length above the takeoff is at least 1.5–2 cm; this leaves adequate urethral length after splitting the common channel. ↗
▶ Ep 11 · 34:26
clinical With inadequate urethral length, do not perform total urogenital mobilization; instead leave the common channel to become the urethra and separate the vagina from it—a technically demanding operation. ↗
▶ Ep 11 · 34:50
clinical After separating vagina from common channel, repair the common channel and cover with anorectal fat pad and possibly SIS to ensure well-healed urethra and avoid urethral-vaginal fistula. ↗
▶ Ep 11 · 35:09
clinical If urogenital mobilization is attempted but the complex does not reach, the only option is abdominal delivery of the urogenital complex; if this fails, separating the vagina from a circumferentially dissected common channel risks devascularizing and losing the urethra. ↗
▶ Ep 11 · 35:52
clinical Urogenital mobilization with inadequate urethral length leaves the patient with urinary leakage that cannot be controlled without tightening or closing the bladder neck. ↗
▶ Ep 11 · 36:05
clinical Separating the vagina from the common channel and leaving the common channel as the entire urethra gives the patient about a 4 cm urethra, allowing intermittent catheterization and continence. ↗
▶ Ep 11 · 36:40
clinical Type 1 cloaca (common channel ~1 cm with adequate urethral length): mobilize the vagina and leave the urethra slightly hypospadiac; patient will void if no neurogenic bladder component. ↗
▶ Ep 11 · 37:11
clinical Patients with tethered cord or neurogenic bladder need a visible urethral orifice that is easily catheterized; slightly hypospadiac urethra is acceptable only if certain the patient will void and not need intermittent catheterization. ↗
▶ Ep 11 · 38:00
clinical When native vagina does not reach after full mobilization, options include vaginal switch (disconnect one side preserving ovarian blood supply, switch dome down, remove septum) or vaginal replacement. ↗
▶ Ep 11 · 38:46
opinion For vaginal replacement, left colon is the preferred option; sigmoid may be used depending on the vascular arcade. ↗
▶ Ep 11 · 39:10
clinical Tissue engineering of vaginas using patient stem cells is on the horizon (work at Wake Forest and Mexico); this would revolutionize cloaca care by eliminating the need for vaginal replacement. ↗
▶ Ep 11 · 39:48
clinical Complex cloacas requiring specialized expertise include those with common channel >3 cm or urethral length (takeoff to bladder neck) <1.5 cm. ↗
▶ Ep 11 · 40:27
clinical The most common problem in redo cloacas is the surgeon never realized it was a cloaca and only fixed the rectum, leaving the urogenital sinus untouched. ↗
▶ Ep 11 · 40:58
clinical The second most common redo problem is inadequate mobilization of structures, leaving the patient with a stenosed or lost vagina. ↗

Colorectal Quiz Episode 17: Cloaca Part 1

▶ Ep 12 · 5:41
epidemiological In the majority of cloaca patients, diagnosis is made at birth rather than prenatally. ↗
▶ Ep 12 · 10:06
quote I really want to emphasize, Richard, what you just said, because I really think that that dogma is no longer valid. ↗
▶ Ep 12 · 10:06
clinical Seattle Children's (Paul McGarrian, Jeff Evansino, Caitlin Smith) demonstrated that many hydrocolpi can be drained perineally, changing prior dogma of routine vaginostomy. ↗
▶ Ep 12 · 10:25
quote I really give Seattle Children's a lot of credit here because they were the ones that said, Paul McGarrian and Jeff Evansino and Caitlin Smith, et cetera, they were the ones that were really saying you can drain a lot of these hydrocolpi, I guess, is that a word? Perineally. ↗
▶ Ep 12 · 10:40
clinical When catheterizing the common channel, the anatomy of the urethral takeoff makes it more likely to enter the vagina than the bladder. ↗
▶ Ep 12 · 10:50
quote If you know the anatomy of the urethral takeoff or to the bladder neck, you're more likely to get into the vagina, frankly, than into the bladder. ↗
▶ Ep 12 · 13:01
clinical Live ultrasound during catheter drainage shows that as the hydrocolpos drains, the bladder fills—demonstrating the pathophysiology of ureteral obstruction by the hydrocolpos. ↗
▶ Ep 12 · 13:40
guideline In almost every cloaca, vesicostomy is unnecessary; the hydrocolpos must be drained, and perineal catheterization can relieve bladder outlet obstruction by decompressing the hydrocolpos and allowing ureters to drain. ↗
▶ Ep 12 · 13:40
quote A vesicostomy is the wrong move here. In almost every cloaca, a vesicostomy is not necessary, but the hydrocolpos needs to be drained. ↗
▶ Ep 12 · 21:37
clinical For massive hydrocolpos requiring open vaginostomy, use a lower midline incision to get above the hydrocolpos, which is very adherent and inflamed against the anterior abdominal wall. A standard left lower quadrant incision will not provide adequate access. ↗
▶ Ep 12 · 21:37
quote If you have a massive hydrocolpos, then you basically should do a lower midline incision. You have to get above the hydrocolpos. And the hydrocolpos is very adherent to the anterior abdominal wall and very inflamed. ↗
▶ Ep 12 · 22:10
clinical For large hydrocolpos, a tubeless vaginostomy can be created by opening the dome, removing part of the septum, and suturing the vagina to the abdominal wall like a vesicostomy or gastrostomy, avoiding an indwelling tube as a nidus for infection. ↗
▶ Ep 12 · 23:08
guideline Single perineal orifice with no anal opening is a cloaca and does NOT require endocrine workup. A perineal orifice with a normal anus is a urogenital sinus and DOES require endocrine workup (e.g., for congenital adrenal hyperplasia). ↗
▶ Ep 12 · 23:30
quote If there is no anus, it is a cloaca. It is not ambiguous genitalia. It is a cloaca. It is a female. And you go on from there. ↗
▶ Ep 12 · 23:40
clinical Urogenital sinus patients can also have hydrocolpos and hydronephrosis, requiring similar drainage management but no colostomy. ↗

Colorectal Quiz Episode 18: Cloaca Part 2

▶ Ep 13 · 7:41
opinion Endoscopy performed by a general pediatric surgeon without extensive cloaca experience has value in distinguishing straightforward from complex cloacas and identifying cases that should be referred to specialized centers. ↗
▶ Ep 13 · 7:59
clinical A major change in cloacal management occurred when surgeons began evaluating complexity before attempting repair and referring difficult cases to high-volume centers, reducing the need for reoperations that were common 10-15 years ago. ↗
▶ Ep 13 · 7:59
quote I think one of the major changes in cloacal management is surgeons realized that they needed to do some evaluation of the complexity of the Cloaca before they attempted a repair. And if they realized that it was a very difficult one, they didn't do the case. They referred the patient to a center that does a lot of these. ↗
▶ Ep 13 · 8:44
opinion Lower confluence cloacas, if the surgeon knows the technique, are a beautiful and elegant operation; higher confluence cloacas requiring vaginal replacement and management of ectopic ureters should be done at specialized centers. ↗
▶ Ep 13 · 8:52
quote The lower confluence, if you know how to do it, is a beautiful, elegant operation. The higher confluence one where vaginal replacements and high vaginas and all of those kind of things, ectopic ureters come into play, probably ought to be done by specialized centers. ↗
▶ Ep 13 · 14:05
quote It is absolutely amazing to me to see this level of detail on a single slide, which I hope everyone recognizes, and I suspect many don't, is probably something like 50 years of work culminated in a single slide. ↗
▶ Ep 13 · 14:11
clinical Hardy Hendren was the father of cloacal management in the late 1960s and 1970s, with specific focus on urology and urethral reconstruction. ↗
▶ Ep 13 · 14:11
quote Hardy Hendren was really the father of cloacal management in the late 1960s and 1970s with a very specific focus on the urology part and urethral reconstruction. ↗
▶ Ep 13 · 14:36
clinical Alberto Peña made a major advance in 1996 with the development of total urogenital mobilization (TUM), which kept the urethra and vagina together as a unit and mobilized them forward; prior to that, all patients had urogenital separation. ↗
▶ Ep 13 · 14:36
quote Alberto Pena, who I was blessed to be mentored by from a young age as a medical student, in 1996, made a major advance in the care of Cloacas with the development of the total urogenital mobilization. Prior to that, all patients had a urogenital separation. He said, why don't we keep the urethra and vagina together as a unit and mobilize that forward? ↗
▶ Ep 13 · 15:05
quote That was in 1996, not that long ago, and then 21 years went by before the next major change in the cloaca protocol. ↗
▶ Ep 13 · 15:10
clinical The next major change in the cloaca protocol occurred 21 years later, in 2017, when the algorithm incorporating urethral length measurement was presented at ABSA. ↗
▶ Ep 13 · 15:28
quote I was in the room in 1996 as Alberto Pena's fellow when he showed Hardy Hendren the TUM and he drew pictures and Hardy Hendren's eyes lit up and said, wow, this is a major advance in cloacal management. ↗
▶ Ep 13 · 16:14
clinical At the 2017 ABSA presentation, 91-year-old Hardy Hendren stated from the microphone that he agreed with everything presented and had no questions. ↗
▶ Ep 13 · 16:14
quote Richard, you presented this at ABSA in 2017, and I was there watching and amazed, and Hardy Hendren himself at the age of 91, got to the microphone and we shuddered a little bit, wondering if he was gonna say something that our work was no good. And he got to the microphone and he said, I have no question. I just have a statement. I agree with everything that's been said. And he sat down. ↗
▶ Ep 13 · 17:03
opinion The 2017 algorithm is the first reproducible approach to cloacal management after 50 years of work on this challenging problem. ↗
▶ Ep 13 · 17:03
quote I just think we need a little bit of historical context because this algorithm that Richard just described is really for the first time, and I've been looking at this stuff for 25 years, the first time that it is reproducible, what to do for Cloacas. ↗
▶ Ep 13 · 18:24
clinical The major change in the 2017 algorithm was the addition of urethral length measurement; previously the decision was based only on common channel length (less than or greater than 3 cm). ↗
▶ Ep 13 · 18:24
quote The major change in this presentation was to make sure you measure the urethral length, because before that, it was common channel less than 3 or greater than 3, and that was it. But now we know that we got to know the urethral length because that will obviously influence what to do for the surgery cause the patient needs appropriately lengthed urethra at the end of the operation. ↗
▶ Ep 13 · 18:39
clinical Measuring urethral length is critical because the patient needs an appropriately lengthed urethra at the end of the operation. ↗

Colorectal Quiz Episode 24: Cloaca Part 3

▶ Ep 14 · 4:43
clinical The protocol has resulted in a significant reduction in the need for redo surgeries, likely because surgeons can define anatomy preoperatively and decide whether to proceed or refer. ↗
▶ Ep 14 · 7:59
quote Common channel. Less than 3 centimeters sets you up for a possible TUM. But, you need to have an adequate urethral length, and that's 1.5 centimeters or greater. Common channel greater than 3 centimeters almost always means a urogenital separation. Period. ↗
▶ Ep 14 · 8:02
clinical Common channel length less than 3 centimeters sets up the possibility for total urogenital mobilization (TUM), but requires adequate urethral length of 1.5 centimeters or greater. ↗
▶ Ep 14 · 8:14
clinical Common channel greater than 3 centimeters almost always means a urogenital separation is required. ↗
▶ Ep 14 · 9:35
clinical When performing TUM, the rectum often reaches even when high, with good mobilization of the urogenital complex. ↗
▶ Ep 14 · 16:12
clinical After TUM mobilization, the common channel is split down the middle, with the two sides becoming the labia minora. ↗
▶ Ep 14 · 19:51
clinical Anterior dissection for TUM requires reaching the retropubic fat and incising the whitish fascia, which releases the complex and gains about 2 to 2.5 centimeters of length. ↗
▶ Ep 14 · 22:13
clinical A short common channel almost always has a good length urethra, though occasionally a short urethra occurs with a low common channel. ↗
▶ Ep 14 · 22:26
clinical Performing TUM in a patient with a short urethra results in the bladder neck at the perineum, which is a miserable result. ↗
▶ Ep 14 · 26:02
clinical For urogenital separation, the common channel should NOT be opened; only a small meatoplasty (1-2 mm) is made to slip in a catheter. ↗
▶ Ep 14 · 26:08
quote Do not open the common channel. Make the meatoplasty just enough to slip a catheter in, maybe 1 or 2 millimeters, but do not touch the common channel. ↗
▶ Ep 14 · 26:36
clinical During posterior sagittal separation, stay very midline because ureters are coming in from the sides. ↗
▶ Ep 14 · 26:36
quote The ureters are coming in from the side, so be careful, stay very midline. ↗
▶ Ep 14 · 26:59
clinical Leaving a little cuff of vaginal tissue during separation allows urology to achieve a really nice urethral closure without tension. ↗
▶ Ep 14 · 35:37
quote We had a problem. We put about 6 brains on the problem, sat down at a devoted meeting, and came up with a list of things that we were gonna do to try to avoid urethral vaginal fistula. We implemented, everyone on the team agreed, haven't had a fistula since. ↗
▶ Ep 14 · 36:09
opinion The most important aspect of preventing urethrovaginal fistula is giving a little cuff of tissue to allow a nice urethral repair with good mucosa and no tension. ↗
▶ Ep 14 · 41:06
quote If you go for a TUM, And it doesn't reach, what do you do? Well, then you need to go into the abdomen and continue your dissection of the urogenital immobilization. Now, on occasion, that's enough, and it does reach, but if it doesn't reach at that point, now you are in some serious trouble, because now you have to do the separation. And guess what? You've already dissected the anterior urethra. ↗
▶ Ep 14 · 41:06
clinical Attempting TUM first and then converting to separation is dangerous because anterior urethral dissection during TUM can compromise blood supply, potentially leaving the patient with no functional urethra if separation is then needed. ↗
▶ Ep 14 · 42:13
clinical Since implementing the measurement protocol, surgeons have never encountered a cloacal anatomy that differed from preoperative expectations. ↗

ERN eUROGEN ARM Webinar Series: Management of Cloacal Malformations – what is new in 2021?

▶ Ep 15 · 4:03
quote This is not a patient with ambiguous genitalia. This is not a patient with urogenital sinus. If the patient has a normal anus, then we can talk about ambiguous genitalia and urogenital sinus. ↗
▶ Ep 15 · 4:03
clinical A patient with no anal opening and a single perineal orifice has a cloaca, not ambiguous genitalia or urogenital sinus. If the patient has a normal anus, then urogenital sinus or ambiguous genitalia can be discussed. ↗
▶ Ep 15 · 4:15
quote If the patient has no anal opening in a single perineal orifice, and here's the perineal orifice, one hole, that patient has a cloaca. ↗
▶ Ep 15 · 4:27
clinical Cloacal patients are normal females with normal typical ovarian anatomy, though a variety of Mullerian anomalies can occur. ↗
▶ Ep 15 · 4:40
clinical The common channel in cloaca emanates just below the clitoral hood, which is not a typical location for the female urethra. ↗
▶ Ep 15 · 5:04
opinion Leaving the urethral opening in the clitoral location is suboptimal both cosmetically and functionally if the patient needs intermittent catheterization. ↗
▶ Ep 15 · 5:04
quote There are some cloacal patients that have been managed where the urethral opening has been left in this location. And I think both cosmetically and functionally, if the patient needs to do intermittent catheterization, this location is suboptimal. ↗
▶ Ep 15 · 8:08
clinical In utero ascites in cloaca occurs when urine flows from the bladder into the vagina, cannot exit the common channel, and backs up through the fallopian tubes into the peritoneal cavity. ↗
▶ Ep 15 · 9:01
clinical The vast majority of hydrocolpos can be drained perineally; many times abdominal surgery is not needed to drain a hydrocolpos. ↗
▶ Ep 15 · 9:12
host_summary Colleagues in Seattle taught that most hydrocolpos, including bilateral cases, can be drained with perineal catheterization. ↗
▶ Ep 15 · 9:23
clinical When hydrocolpos is decompressed perineally, the bladder will suddenly dilate because there is less pressure on the distal ureters, allowing them to empty into the bladder. ↗
▶ Ep 15 · 9:46
clinical A vesicostomy in almost all cloacas is not the correct treatment because it will not solve the distal ureteral obstruction. ↗
▶ Ep 15 · 9:46
quote A vesicostomy in almost all cloacass is not the correct treatment because it will not solve the distal ureteral obstruction. ↗
▶ Ep 15 · 10:37
epidemiological About 40% of cloacal patients have a bifid vaginal system. ↗
▶ Ep 15 · 10:46
clinical Hydrocolpos only needs to be managed if it is causing hydronephrosis. ↗
▶ Ep 15 · 12:10
clinical The measurements vital in cystoscopy are the bladder neck location, the length of the common channel, and the length of the urethra. The urethral length must not be forgotten. ↗
▶ Ep 15 · 12:19
quote Don't forget that we must know the length of the urethra. ↗
▶ Ep 15 · 12:26
clinical Cloacas form in two groups: those with a low confluence and those with a high confluence. ↗
▶ Ep 15 · 12:34
clinical Historically, total urogenital mobilization was done based on common channel measurement alone, but this was done in some cases for patients with inadequately lengthed urethra. ↗
▶ Ep 15 · 13:01
host_summary Doctor Hendren historically did only urogenital separations, and then Doctor Pena in 1996 showed the total urogenital mobilization, which was brilliant but overused for patients who did not have an adequately length urethra. ↗
▶ Ep 15 · 13:08
quote Doctor Pena, my mentor in 1996, showed the total urogenital mobilization. Which was brilliant, but I believe it was overused for patients who did not have an adequately length urethra. ↗
▶ Ep 15 · 13:23
clinical Most low confluence cloacas have a long urethra, and when long means greater than 1.5 centimeters, which is needed for bladder function. ↗
▶ Ep 15 · 13:31
quote You do not want to disrupt the urogenital diaphragm. You do not want to pull the bladder neck down out of the urogenital diaphragm. You'll end up with urinary leakage. ↗
▶ Ep 15 · 13:31
clinical You do not want to disrupt the urogenital diaphragm or pull the bladder neck down out of the urogenital diaphragm, as this will result in urinary leakage. ↗
▶ Ep 15 · 14:01
clinical For a patient with a 3.5 cm common channel and only 1.5 cm native urethra, the preference is to do rectal mobilization, vaginal mobilization, repair the back of the common channel, and leave the urethra to become 5 cm (native urethra plus common channel), which is more likely to result in a dry patient. ↗
▶ Ep 15 · 14:34
quote If you did a TUM on this patient, you would leave the patient with a very short urethra, pulled down all the way to the perineum. ↗
▶ Ep 15 · 15:56
clinical The distinction between TUM versus UG separation is based on: common channel length (3 cm or less is low confluence, likely TUM; greater than 3 cm is high confluence, likely UG separation) and urethral length (if urethra cannot be guaranteed to be 1.5 cm or greater, must do UG separation). ↗
▶ Ep 15 · 16:28
clinical A study of patients who underwent VCUG because of UTI found them to have at least 1.5 cm, if not greater, urethral length, which is where the recommendation for minimum urethral length comes from. ↗
▶ Ep 15 · 17:19
quote If you were to split a long common channel, and there's very little urethra on the other side of it, You're essentially bringing the bladder neck down to the perineum, which must be avoided. ↗
▶ Ep 15 · 17:19
clinical If you split a long common channel and there is very little urethra on the other side, you are essentially bringing the bladder neck down to the perineum, which must be avoided. ↗
▶ Ep 15 · 18:28
clinical For a hypospadic urethra 1 cm away, you could consider leaving it hypospadic and doing only vaginal mobilization and introitoplasty, but must recognize the urethra might need catheterization one day, particularly if the patient has a spinal issue like tethered cord. ↗
▶ Ep 15 · 19:05
clinical The TUM itself may be needed just to mobilize the posterior vagina to get the introitus to reach comfortably. ↗
▶ Ep 15 · 19:19
clinical A new technique involves making an incision in the posterior common channel to recess the urethral meatus below the clitoral hood for better cosmesis and catheterization access. ↗
▶ Ep 15 · 20:18
clinical Occasionally the vagina does not reach and requires vaginal replacement, ideally using a segment of sigmoid colon. ↗
▶ Ep 15 · 20:40
clinical A nice trick for vaginal replacement is to use the sigmoid colostomy site itself, taking a segment needed for vaginal replacement and then recreating the colostomy slightly more proximal. ↗
▶ Ep 15 · 21:17
quote I do believe a key future endeavor relative to cloacal repair will be tissue engineering, and in theory, you have a vagina that doesn't reach in the urethra, you don't want to mobilize, you could sew in a tissue engineered vagina from that very patient, which you have selected and created in the lab over the prior 3 months by using their stem cells. I do believe this is going to happen in our lifetime. ↗
▶ Ep 15 · 21:17
opinion Tissue engineering for vaginal replacement is a key future endeavor; in theory, a tissue engineered vagina could be created from the patient's own stem cells over 3 months in the lab. ↗
▶ Ep 15 · 23:13
clinical The best time for cloacal correction is somewhere between 2 months and 1 year, with most repairs done at about 6 to 8 months of age. ↗
▶ Ep 15 · 25:51
clinical Fine needle cautery at low setting (usually 10, pure and spray for cut and coag) staying full thickness outside the TUM plane has not caused problems with stricture or fistula. ↗
▶ Ep 15 · 26:19
clinical Complications of PSARP are quite minimal with good technique, but rectal stricture can occur. When the vagina is mobilized and separated from the common channel, if under tension, vaginal stenosis can result. ↗
▶ Ep 15 · 26:45
clinical For vaginal stenosis after repair, as long as there is an opening, would not intervene at that point; would let the patient go through puberty and maybe consider an introitoplasty much later in life. ↗
▶ Ep 15 · 27:24
epidemiological For patients with greater than 3 cm common channel who undergo UG separation, 4 out of 5 (80%) will need intermittent catheterization. For those with 3 cm or less common channel, 1 out of 5 need intermittent catheterization. ↗
▶ Ep 15 · 28:19
clinical There is definitely increased mucus production with a bowel neovagina, so if it can be avoided, it should be, but it should be done if the vagina doesn't reach successfully to the perineum. ↗
▶ Ep 15 · 28:36
clinical There is some literature on pregnancy in cloacal patients. A few patients have become pregnant, and C-section is definitely advised because of the extensive perineal dissection. ↗
▶ Ep 15 · 29:05
clinical For stenotic vagina post-op, if the orifice is there, would leave the patient alone, let them go through puberty, and maybe do an introitoplasty later in life. ↗
▶ Ep 15 · 29:17
clinical If the vagina has disappeared post-op, a very good time to correct it might be at the time of colostomy closure when you can take the colostomy site itself and bring down a neovagina independently. ↗
▶ Ep 15 · 29:43
host_summary Laparoscopic or robotic UG separation has been done by colleagues including Doctor Wood in Columbus and Belinda Dickey in Boston. Cases take a long time but are elegant and beautiful, and are a good approach for patients who would require laparotomy. ↗
▶ Ep 15 · 30:32
opinion The number of redo operations has dramatically reduced because surgeons are doing anatomy analysis first, doing it well, and not attempting complex cases they don't feel comfortable with. ↗
▶ Ep 15 · 31:02
opinion In the speaker's hands, TUM is a very straightforward case with very good results, virtually no vaginal stenosis, and a very good urethral repair. ↗
▶ Ep 15 · 31:22
clinical From a technical point of view, if dissecting the rectum and perineal body, vaginal replacement if needed should be done then, though it is much more difficult to do as a teenager. ↗
▶ Ep 15 · 32:14
clinical Vaginal switch operation is no longer done; those patients ended up with a lot of stenosis. ↗
▶ Ep 15 · 32:37
clinical Neovaginal dilatation is not done; would rather allow for a skin-level stenosis and later do an introitoplasty rather than subject the patient to vaginal dilatation. ↗
▶ Ep 15 · 32:54
clinical The perineal sphincter muscle complex is absolutely preserved during a posterior sagittal repair. ↗
▶ Ep 15 · 33:12
clinical For perineal vaginal drainage, the common channel may need catheterization 2 or 3 times per day. The baby may start to void between catheterizations, which can be followed on ultrasound. ↗
▶ Ep 15 · 33:26
clinical Families are taught how to catheterize and brought to radiology to confirm by ultrasound that they are putting the perineal catheter in the correct location. Sometimes it needs to be directed right or left if there is bilateral hydrocolpos. A Coude catheter is useful because it can be twisted and directed. ↗
▶ Ep 15 · 34:09
clinical When doing UG separation, dissection starts on the back of the vagina as it enters the common channel, lifting it up off the common channel and dissecting the plane between vagina and posterior urethra. Do not touch the common channel at all to avoid getting into spongiosum tissue. ↗
▶ Ep 15 · 35:25
clinical Personal preference is to always start posterior sagittally if the confluence is low, below the peritoneal reflection. In the rare case where vagina and rectum are in the abdomen already, would start in the abdomen. ↗
▶ Ep 15 · 35:48
clinical With laparoscopy or robotics, you can go much lower than with laparotomy, but you want to get to the very end of vaginal insertion onto the common channel, which is hard to do. It's easier to start posterior sagittally and then go into the abdomen to continue that dissection. ↗
▶ Ep 15 · 36:36
clinical A TUM can always be done in prone position. If a TUM doesn't reach, can go into the abdomen, mobilize the confluence together, and pull through, but in such a case it would have been better to do a separation, not a TUM. ↗
▶ Ep 15 · 38:10
clinical The key to saving kidneys in cloaca is keeping the bladder empty through aggressive intermittent catheterization and bladder management, with vesicostomy in appropriate patients, particularly those with grade 4 or 5 reflux. This is learned from spina bifida management. ↗
▶ Ep 15 · 38:49
clinical Small bowel is the second choice after colon for neovagina. The blood supply of small bowel is quite tenuous and not as forgiving as that of colon. ↗
▶ Ep 15 · 39:21
opinion Personal preference is to do the entire cloacal operation together rather than staging the rectum first and doing UG mobilization later, though it is reasonable to do TUM later if it can be done perineally without touching the rectum. ↗
▶ Ep 15 · 40:00
clinical Perineal body length is individualized, measured from the bottom of the labia where they meet in the middle to the anterior limit of the anal sphincter. Everything in between is the perineal body. ↗
▶ Ep 15 · 40:32
clinical Hydrocolpos can recur after procedure if vaginal stenosis occurs. In that case, would dilate up the vaginal opening to allow flow. Usually vaginal stenosis is quite skin level and does allow drainage of mucus. ↗
▶ Ep 15 · 40:57
clinical There is rarely an occasion to close the bladder neck because most urethras are salvageable if you respect the principle of keeping the common channel intact to become the neourethra. They all have a smooth, catheterizable common channel, but you need to get the vagina off of it. ↗
▶ Ep 15 · 41:32
clinical Only in very rare circumstances of congenital urethral atresia, where the patient never was able to drain urine and drained urine out the fallopian tubes with in utero ascites, do those patients need vesicostomy at birth and ultimately a Mitrofanoff. ↗
▶ Ep 15 · 43:58
clinical Colon is preferred over small bowel for vaginal replacement for its more sturdy blood supply and because using the left colon at the colostomy site saves an anastomosis by taking the colostomy down and making a more proximal colostomy. ↗
▶ Ep 15 · 45:32
clinical Patients are plugged into the concept of transition at about age 12 because that's when girls are going through puberty and need gynecology colleagues. Officially at age 21 they no longer are seen at Children's Hospital, though can flex till about age 30 if needed. ↗

Colorectal Quiz: Episode 40

▶ Ep 21 · 1:39
epidemiological Anorectal malformation occurs more commonly in females and has a prevalence of about one in 5,000 births. ↗
▶ Ep 21 · 2:21
quote We've talked about this before on some of these rare circumstances. ↗
▶ Ep 21 · 2:21
clinical When you look in laparoscopically and see an end of the colon with nothing else visible, you do not have to do a divided colostomy—you can bring out that distal end as your stoma rather than interfering with the blood supply for the distal segment. ↗
▶ Ep 21 · 2:21
quote When you look in and you see an end of the colon and that's all you see, you do not have to do a divided colostomy. That can be the end. That can be your colostomy. ↗
▶ Ep 21 · 2:59
quote I think the smartest thing to do in this very rare case is make a true end colostomy. ↗
▶ Ep 21 · 2:59
opinion The only potential benefit of doing a divided colostomy when encountering blind-ending colon is protecting the ultimate rectal repair, but this risks the blood supply to the distal rectum. ↗
▶ Ep 21 · 5:32
clinical Meyer-Rokitansky-Küster-Hauser syndrome can present with anorectal malformation, creating Meyer-Rokitansky-like anatomy where ovaries and remnant tubes are present but no midline Müllerian structures. ↗
▶ Ep 21 · 6:37
clinical The more common scenario of anorectal malformation with absent vagina is a recto-vestibular fistula with 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. ↗
▶ Ep 21 · 7:08
clinical In this case, the rectum ended blind and quite high in the pelvis, making it unreachable through a posterior sagittal incision. ↗
▶ Ep 21 · 7:18
clinical The foreshortened sacrum in this case suggests caudal regression, where everything below that level forgot to develop. ↗
▶ Ep 21 · 10:12
clinical Not diverting after limited posterior sagittal anorectoplasty is safe when you have a colocolonic anastomosis at the colostomy closure site and only an anoplasty with a couple of posterior sutures. ↗
▶ Ep 21 · 11:04
clinical In the past, vaginal replacement would have been done at the same time as rectal repair in these patients, but time and research have shown that colonic neovaginas are not great for patients 20 years down the road, and surgeons should try very hard to avoid them. ↗
▶ Ep 21 · 11:04
quote In the past, a vaginal replacement would have been done at the same time as the rectal repair in these patients. However, time and research have shown that colonic neovaginas are not great for patients 20 years down the road. And we should try very hard to avoid them. ↗
▶ Ep 21 · 11:35
clinical In most cloacas, you should be able to get the native vagina to reach without needing vaginal replacement. ↗
▶ Ep 21 · 11:35
quote I can tell you in most cloacas, you should be able to get the native vagina to reach. ↗
▶ Ep 21 · 12:46
host_summary A theoretical approach proposed by gynecologist Alison May for cloaca cases where native vagina doesn't reach is to provide a neovagina as a bridge so the patient can menstruate through it, then potentially remove it 20 years later. ↗
▶ Ep 21 · 14:50
clinical Vascular anomalies associated with anorectal malformation have not been much written about in the literature. ↗
▶ Ep 21 · 15:11
clinical An aberrant external iliac artery can loop up within the abdominal wall, looking very much like the obliterated umbilical artery, while actually being a blood supply to one of the extremities. ↗
▶ Ep 21 · 15:11
quote I vividly remember a case where we encountered an aberrant external iliac artery that looped up and actually was within the abdominal wall and looked very much like the obliterated umbilical artery and in fact was a blood supply to one of the extremities. ↗

Colorectal Quiz: Episode 40

▶ Ep 22 · 1:39
epidemiological Anorectal malformation occurs more commonly in females and has a prevalence of about one in 5,000 births. ↗
▶ Ep 22 · 2:21
clinical When laparoscopy reveals a blind-ending colon with no distal segment visible, an end colostomy is preferable to a divided colostomy to avoid interfering with blood supply to the distal rectum. ↗
▶ Ep 22 · 2:21
quote When you look in and you see an end of the colon and that's all you see, you do not have to do a divided colostomy. That can be the end. That can be your colostomy. ↗
▶ Ep 22 · 2:59
opinion The only potential benefit of a divided colostomy when a blind-ending colon is seen is protecting the ultimate rectal repair, but this risks the blood supply to the distal rectum. ↗
▶ Ep 22 · 5:32
clinical Meyer-Rokitansky-Küster-Hauser syndrome can occur with an anorectal malformation, though it is extremely rare. ↗
▶ Ep 22 · 5:35
quote It is Meyer-Rotakansky-like in that there are ovaries, there are scrawny little tubes, probably remnants, and then nothing else. No midline structure at all. ↗
▶ Ep 22 · 6:37
clinical The more common scenario is a recto-vestibular fistula with a completely normal urethra but no vagina in between (distal vaginal atresia), where the rectum ends as a fistula in the vestibule. ↗
▶ Ep 22 · 7:08
clinical In this case, the rectum ends blind and quite high in the pelvis, unreachable through a posterior sagittal incision. ↗
▶ Ep 22 · 7:18
clinical The sacrum appears foreshortened on imaging, suggesting caudal regression where everything below a certain level forgot to develop. ↗
▶ Ep 22 · 8:31
quote You couldn't safely dig through all those pulsating vessels with laparoscopes, right? ↗
▶ Ep 22 · 10:12
clinical Not diverting was considered safe because there was a colocolonic anastomosis at the colostomy closure site and only an analplasty with a couple of posterior sutures, unlike Hirschsprung's disease where distal obstruction from non-relaxing sphincters could blow out the anastomosis. ↗
▶ Ep 22 · 11:14
quote In the past, a vaginal replacement would have been done at the same time as the rectal repair in these patients. However, time and research have shown that colonic neovaginas are not great for patients 20 years down the road. ↗
▶ Ep 22 · 11:14
clinical In the past, vaginal replacement would have been done at the same time as rectal repair, but time and research have shown that colonic neovaginas are not great for patients 20 years down the road and should be avoided. ↗
▶ Ep 22 · 11:35
clinical In most cloacas, the native vagina should be able to reach and vaginal replacement should be avoided. ↗
▶ Ep 22 · 11:56
quote I think in 20 years or perhaps even shorter, we're going to have tissue engineering options. ↗
▶ Ep 22 · 11:56
clinical A buccal graft could be laid into the opened introitus area as an alternative to dilation. ↗
▶ Ep 22 · 12:34
quote I think really in these, these days, one can completely avoid a vaginal replacement. ↗
▶ Ep 22 · 12:34
opinion One can completely avoid vaginal replacement in these cases in the current era. ↗
▶ Ep 22 · 12:46
clinical Gynecologist Alison May proposed providing a neovagina as a temporary bridge so the patient can menstruate, with potential removal 20 years later when tissue engineering becomes available. ↗
▶ Ep 22 · 13:21
clinical Using the remaining colon in this patient for vaginal replacement would be very risky due to compromised blood supply from the prior divided stoma. ↗
▶ Ep 22 · 14:09
quote There's going to be a real estate problem. ↗
▶ Ep 22 · 15:11
quote I vividly remember a case where we encountered an aberrant external iliac artery that looped up and actually was within the abdominal wall and looked very much like the obliterated umbilical artery and in fact was a blood supply to one of the extremities. ↗
▶ Ep 22 · 15:11
clinical Vascular anomalies associated with anorectal malformations have not been much written about in the literature. ↗
▶ Ep 22 · 15:11
clinical Mark Levitt recalls a case with an aberrant external iliac artery that looped up within the abdominal wall, resembling the obliterated umbilical artery but actually supplying blood to an extremity. ↗
▶ Ep 22 · 17:13
opinion The odds of continence for this child are concerning given the anatomy. ↗
▶ Ep 22 · 17:13
quote The odds of continence for this child are concerning. ↗
▶ Ep 22 · 17:39
clinical The patient is not leaking urine all the time, which is a positive finding for future continence. ↗

Colorectal Quiz Episode 18: Cloaca Part 2

▶ Ep 23 · 14:04
clinical Hardy Hendren was the father of cloacal management in the late 1960s and 70s with specific focus on urology and urethral reconstruction ↗
▶ Ep 23 · 14:04
quote It is absolutely amazing to me to see this level of detail on a single slide, which I hope everyone recognizes, and I suspect many don't, is probably something like 50 years of work culminated in a single slide. ↗
▶ Ep 23 · 14:30
clinical Alberto Pena made a major advance in cloacal care in 1996 with development of total urogenital mobilization (TUM), which kept the urethra and vagina together as a unit for mobilization ↗
▶ Ep 23 · 14:50
clinical Prior to 1996, all cloaca patients had urogenital separation ↗
▶ Ep 23 · 15:14
clinical The next major change in cloaca protocol after TUM came 21 years later in 2017 with the algorithmic approach incorporating urethral length measurement ↗
▶ Ep 23 · 15:40
quote I was in the room in 1996 as Alberto Pena's fellow when he showed Hardy Hendren the TUM and he drew pictures and Hardy Hendren's eyes lit up and said, wow, this is a major advance in cloacal management. ↗
▶ Ep 23 · 16:10
clinical Hardy Hendren at age 91 attended the 2017 APSA presentation of the new algorithm and stated he agreed with everything presented ↗
▶ Ep 23 · 16:20
quote Hardy Hendren himself at the age of 91 got to the microphone and we shuddered a little bit wondering if he was going to say something that our work was no good. And he got to the microphone and he said, I have no question. I just have a statement. I agree with everything that's been said. ↗
▶ Ep 23 · 16:50
opinion The 2017 algorithm is the first time cloacal management has been reproducible ↗
▶ Ep 23 · 18:13
clinical The major change in the 2017 algorithm was ensuring measurement of urethral length, whereas previously only common channel length (<3 cm or >3 cm) was considered ↗

Colorectal Quiz Episode 17: Cloaca Part 1

▶ Ep 24 · 4:43
opinion A smart perinatologist seeing a female fetus with pelvic mass and kidney abnormalities should consider cloaca diagnosis, which influences delivery location. ↗
▶ Ep 24 · 5:00
quote If they know it's a female and there's a pelvic mass and something wrong with the kidneys, a smart perinatologist will say maybe a cloaca is about to be born. ↗
▶ Ep 24 · 5:57
clinical Neonatologists might incorrectly conclude cloaca is ambiguous genitalia and do unnecessary endocrine workup. ↗
▶ Ep 24 · 10:06
clinical Seattle Children's (Paul McGarrian, Jeff Evan Sino, Caitlin Smith) demonstrated that many hydrocolpi can be drained perineally, changing the previous dogma of routine vaginostomy. ↗
▶ Ep 24 · 10:20
quote I really give Seattle Children's a lot of credit here, because they were the ones that said, Paul McGarrian and Jeff Evan Sino and Caitlin Smith, et cetera, they were the ones that were really saying you can drain a lot of these hydrocolpi, I guess, is that a word, perineally. ↗
▶ Ep 24 · 10:40
clinical When catheterizing for hydrocolpos drainage, you are more likely to get into the vagina than the bladder due to the anatomy of the urethral takeoff to the bladder neck. ↗
▶ Ep 24 · 10:50
quote If you know the anatomy of the urethral takeoff or to the bladder neck, you're more likely to get into the vagina, frankly, than into the bladder. ↗
▶ Ep 24 · 11:45
clinical The modern hydrocolpos drainage approach is published in a Seminars in Pediatric Surgery article but not yet in textbooks. ↗
▶ Ep 24 · 13:11
clinical During ultrasound-guided drainage, when you drain the hydrocolpos, the bladder immediately fills, demonstrating the physiology where hydrocolpos obstructs the ureters. ↗
▶ Ep 24 · 13:11
quote While you're doing an ultrasound, if you put the catheter into the hydrocopos, not only do you drain all that urine that's been accumulated in there, but as soon as you do that drainage, guess what? The bladder fills, which is exactly the physiology that's so problematic about the hydrocopos, because the hydrocopos is obstructing the ureters. ↗
▶ Ep 24 · 13:40
quote A vesicostomy is the wrong move here. In almost every cloaca, a vesicostomy is not necessary, but the hydrocopos needs to be drained. ↗
▶ Ep 24 · 13:40
opinion A vesicostomy is the wrong move in almost every cloaca; the hydrocolpos needs to be drained instead. ↗
▶ Ep 24 · 13:59
clinical Once hydrocolpos is drained, ureters are no longer compressed at the trigone and can empty into the bladder, which then empties out the common channel or back into hydrocolpos for sequential drainage. ↗
▶ Ep 24 · 21:37
clinical For massive hydrocolpos requiring open approach, use lower midline incision to get above the hydrocolpos, which is very adherent to anterior abdominal wall and inflamed; standard left lower quadrant incision will cause trouble. ↗
▶ Ep 24 · 22:20
clinical For large hydrocolpos via midline: open into dome, remove bit of septum, close it, put in tube to drain both sides, or suture to abdominal wall like vesicostomy/gastrostomy to avoid indwelling tube as nidus for infection. ↗
▶ Ep 24 · 22:51
clinical Critical distinction: single perineal orifice with no anal opening is cloaca (female, no endocrine workup); completely normal anus with perineal orifice is urogenital sinus (needs endocrine workup for CAH, electrolyte check). ↗
▶ Ep 24 · 23:55
quote Once again, single peroneal orifice with no anal opening is a cloaca and does not need an endocrine workup, whereas a peroneal opening with a normal anus is a ugesinus and does need an endocrine workup. ↗
▶ Ep 24 · 23:55
clinical Urogenital sinus patients can also have hydrocolpos and hydronephrosis with similar management, but no colostomy needed since they have an anus. ↗
Colorectal / ARM & Hirschsprung 136 entries

How I Do It Levitt PSARP

▶ Ep 8 · 0:20
clinical A no-fistula anorectal malformation defect is managed very similarly to a bulbar urethral fistula. ↗
▶ Ep 8 · 0:45
quote Obviously the key to starting any such case is a good imaging study. ↗
▶ Ep 8 · 0:45
clinical The key to starting any anorectal malformation repair is a good imaging study. ↗
▶ Ep 8 · 1:05
clinical Fistula levels can be classified anatomically: bladder neck fistula is at the deltoid level (C), rectoprostatic fistula is at the triceps level (B), and rectobulbar fistula is at the elbow of the urethral curve or distal (A). ↗
▶ Ep 8 · 1:50
clinical It is important to mark the sphincter location before making the posterior sagittal incision because once the incision is made, it is hard to know exactly where the sphincter center is. ↗
▶ Ep 8 · 2:28
clinical The sphincters must be cut perfectly in the midline so that they can be easily reconstructed. ↗
▶ Ep 8 · 2:42
clinical Without a good distal colostogram, the midline whitish structure at the center of the dissection could be the urinary tract rather than the rectum. ↗
▶ Ep 8 · 2:46
quote If you don't have a good distal colostogram, this midline whitish structure could very easily be the urinary tract. ↗
▶ Ep 8 · 3:06
quote You don't want to hurt the urethra. ↗
▶ Ep 8 · 3:21
clinical Lateral dissection should be performed before turning attention anteriorly during rectal mobilization. ↗
▶ Ep 8 · 3:27
quote That is the critical moment. You want to separate the rectum from the urinary tract below without injuring the urinary tract. ↗
▶ Ep 8 · 3:35
clinical The initial anterior dissection to separate rectum from urinary tract is a submucosal dissection for the first few millimeters. ↗
▶ Ep 8 · 3:40
quote Imagine you are literally dropping down the urinary tract as the rectum is lifted up. ↗
▶ Ep 8 · 4:11
quote If you're not sure, go lateral. ↗
▶ Ep 8 · 4:14
clinical During lateral dissection, any fat seen means you can get closer to the rectum safely. ↗
▶ Ep 8 · 4:14
quote When you're lateral, any fat you see means you can get closer to the rectum. ↗
▶ Ep 8 · 4:23
clinical The lower the rectum is positioned, the longer is the common wall between rectum and urinary tract. ↗
▶ Ep 8 · 4:29
opinion A lower rectum is easier to repair in one sense but harder because there is a longer dissection adjacent to the urethra. ↗
▶ Ep 8 · 4:38
opinion A rectum at the bulbar level is too low to approach laparoscopically and is much safer to approach posterior sagittally. ↗
▶ Ep 8 · 4:41
quote That is way too low in my opinion to approach laparoscopically, much safer to approach such an operation posterior sagittally. ↗
▶ Ep 8 · 4:51
clinical Approaching a low rectum laparoscopically risks leaving behind distal rectum, a remnant of the urethral fistula, or a roof. ↗
▶ Ep 8 · 5:13
quote If you see fat, you can get closer. ↗
▶ Ep 8 · 5:16
clinical The rectum must be in the correct dissection plane or it will not mobilize properly. ↗
▶ Ep 8 · 5:16
quote You must be in the correct plane, otherwise the rectum does not mobilize. ↗
▶ Ep 8 · 5:44
clinical When closing the muscle complex, taking a bite of the rectum helps to avoid prolapse. ↗
▶ Ep 8 · 5:54
clinical The rectum should lie adjacent to, not constricted by, the muscle complex. ↗
▶ Ep 8 · 6:15
clinical As much rectum as possible should be preserved during the repair. ↗
▶ Ep 8 · 6:32
clinical The anoplasty is performed with 16 sutures under slight tension so that when stitches are cut, the rectum will gently retract and appear like a normal anus. ↗
▶ Ep 8 · 6:52
clinical Dilations begin at 2 weeks postoperatively. ↗
▶ Ep 8 · 6:52
clinical Colostomy closure can take place 2 to 3 months after PSARP once the anus has reached its desired size. ↗

Hirschsprung Disease Part I with Marc Levitt

▶ Ep 28 · 8:43
clinical The best treatment for Hirschsprung disease is irrigations using a large bore tube (20 French Foley) with warm saline, instilling 10-20 cc aliquots at a time and allowing fluid mixed with stool to drain back. ↗
▶ Ep 28 · 8:43
clinical The best treatment for Hirschsprung disease is irrigations using a large bore tube (20 French Foley) with warm saline, instilling 10-20 cc aliquots at a time and allowing fluid mixed with stool to drain back. ↗
▶ Ep 28 · 8:55
clinical It is very rare that Hirschsprung disease is a surgical emergency, but if you don't irrigate and overcome the distal obstruction, it will become an emergency. ↗
▶ Ep 28 · 8:55
quote It is very rare that Hirschberg's disease is a surgical emergency. But if you don't irrigate and overcome the distal obstruction, it will become an emergency. ↗
▶ Ep 28 · 8:55
clinical It is very rare that Hirschsprung disease is a surgical emergency, but if you don't irrigate and overcome the distal obstruction, it will become an emergency. ↗
▶ Ep 28 · 8:55
quote It is very rare that Hirschberg's disease is a surgical emergency. But if you don't irrigate and overcome the distal obstruction, it will become an emergency. ↗
▶ Ep 28 · 9:13
quote If you take a large bore tube, like a 20 French Foley, and get some warm saline irrigation, I take a 60 cc non-morlock syringe. And I basically um insert about 10 to 20 cc aloquats at a time, passing it with the lubricant, of course, instilling saline, moving the tube to and fro, advancing it as far as you can without needing resistance, and then you take the 60 cc syringe off the tube and let the fluid mixed with stool drip back. ↗
▶ Ep 28 · 9:13
quote If you take a large bore tube, like a 20 French Foley, and get some warm saline irrigation, I take a 60 cc non-morlock syringe. And I basically um insert about 10 to 20 cc aloquats at a time, passing it with the lubricant, of course, instilling saline, moving the tube to and fro, advancing it as far as you can without needing resistance, and then you take the 60 cc syringe off the tube and let the fluid mixed with stool drip back. ↗
▶ Ep 28 · 11:02
quote Babies with Hirschberg's disease have no ability to expel the enema fluid. ↗
▶ Ep 28 · 11:02
quote Babies with Hirschberg's disease have no ability to expel the enema fluid. ↗
▶ Ep 28 · 12:38
clinical For rectal biopsy in suspected Hirschsprung disease, you must be at least 1 centimeter in from the dentate line. If you biopsy too close to the dentate line, everyone has an aganglionic segment there and you could get the wrong answer. ↗
▶ Ep 28 · 12:38
clinical For rectal biopsy in suspected Hirschsprung disease, you must be at least 1 centimeter in from the dentate line. If you biopsy too close to the dentate line, everyone has an aganglionic segment there and you could get the wrong answer. ↗
▶ Ep 28 · 13:03
quote You have to be careful not to biopsy too high. If the gun gets sent in too, too deep and biopsies at 4 or 5 centimeters, which I have seen happen, you may miss a lower zone of Hirschberg's disease. ↗
▶ Ep 28 · 13:03
quote You have to be careful not to biopsy too high. If the gun gets sent in too, too deep and biopsies at 4 or 5 centimeters, which I have seen happen, you may miss a lower zone of Hirschberg's disease. ↗
▶ Ep 28 · 13:23
quote The pathologist really needs to be prepared for evaluation of Hirschberg's disease, and you as the surgeon cannot accept a pathologist's report unless there is the absence of ganglion cells and the presence of hypertrophic nerves. The absence of ganglion cells alone is not Hirschberg's disease. ↗
▶ Ep 28 · 13:23
clinical The pathologist must report both the absence of ganglion cells AND the presence of hypertrophic nerves. The absence of ganglion cells alone is not Hirschsprung disease - that could be a biopsy taken too low. ↗
▶ Ep 28 · 13:23
quote The pathologist really needs to be prepared for evaluation of Hirschberg's disease, and you as the surgeon cannot accept a pathologist's report unless there is the absence of ganglion cells and the presence of hypertrophic nerves. The absence of ganglion cells alone is not Hirschberg's disease. ↗
▶ Ep 28 · 13:23
clinical The pathologist must report both the absence of ganglion cells AND the presence of hypertrophic nerves. The absence of ganglion cells alone is not Hirschsprung disease - that could be a biopsy taken too low. ↗
▶ Ep 28 · 14:35
quote Interestingly, if you put a cork in a newborn baby and they didn't stool for one week. They would not get sick. They would just be distended and have hard stool. But Hirschprung's disease has an immune component to it, and the, the lining of the bowel, the mucosa, is much more susceptible to translocation. ↗
▶ Ep 28 · 14:35
quote Interestingly, if you put a cork in a newborn baby and they didn't stool for one week. They would not get sick. They would just be distended and have hard stool. But Hirschprung's disease has an immune component to it, and the, the lining of the bowel, the mucosa, is much more susceptible to translocation. ↗
▶ Ep 28 · 14:59
clinical Hirschsprung disease has an immune component and the lining of the bowel (mucosa) is much more susceptible to bacterial translocation. Stasis in a Hirschsprung patient leads to bacterial translocation and a very sick baby from bacteremia. ↗
▶ Ep 28 · 14:59
clinical Hirschsprung disease has an immune component and the lining of the bowel (mucosa) is much more susceptible to bacterial translocation. Stasis in a Hirschsprung patient leads to bacterial translocation and a very sick baby from bacteremia. ↗
▶ Ep 28 · 15:42
clinical If irrigations are not working and the baby is ill, you need to divert. The recommendation is to divert in the ileum rather than doing a leveling colostomy, because frozen section can be inaccurate, particularly as you move higher in the colon. ↗
▶ Ep 28 · 15:42
clinical If irrigations are not working and the baby is ill, you need to divert. The recommendation is to divert in the ileum rather than doing a leveling colostomy, because frozen section can be inaccurate, particularly as you move higher in the colon. ↗
▶ Ep 28 · 18:14
clinical The Swenson operation involved full-thickness transabdominal dissection down below the peritoneal reflection. The operation was often done incorrectly with perirectal dissection done too wide, leading to fecal incontinence, urinary incontinence, sexual problems, and impotence. ↗
▶ Ep 28 · 18:14
clinical The Swenson operation involved full-thickness transabdominal dissection down below the peritoneal reflection. The operation was often done incorrectly with perirectal dissection done too wide, leading to fecal incontinence, urinary incontinence, sexual problems, and impotence. ↗
▶ Ep 28 · 19:28
clinical The Suave operation used a mucosal dissection to keep the outer rectal wall intact and avoid injury. The original Suave would leave the colon coming through the anus for a week before doing the coloanal anastomosis; Dr. Scott Boley modified it to do everything in one stage. ↗
▶ Ep 28 · 19:28
clinical The Suave operation used a mucosal dissection to keep the outer rectal wall intact and avoid injury. The original Suave would leave the colon coming through the anus for a week before doing the coloanal anastomosis; Dr. Scott Boley modified it to do everything in one stage. ↗
▶ Ep 28 · 20:18
clinical The Duhamel operation leaves the original rectum in place, removes the aganglionic portion from the peritoneal reflection, and pulls ganglionic bowel in a retrorectal position, connecting the two lumens with a stapler. ↗
▶ Ep 28 · 20:18
clinical The Duhamel operation leaves the original rectum in place, removes the aganglionic portion from the peritoneal reflection, and pulls ganglionic bowel in a retrorectal position, connecting the two lumens with a stapler. ↗
▶ Ep 28 · 21:18
clinical Of the four classic procedures (Swenson, Suave, Duhamel, Rabine), only the Swenson actually leaves behind virtually no Hirschsprung tissue. The others leave behind outer rectal wall or original rectum. Many patients did well despite this because ganglionic bowel, if it's good, can overcome a lot. ↗
▶ Ep 28 · 21:18
quote It's fascinating actually that, you know, of those four procedures, the only one that actually leaves behind virtually no Hirschprungs is the Swenson. The suave leaves behind the outer rectal wall. The Duhamel leaves behind the original rectum, and the ravine leaves behind the original rectum as well. Amazingly, many, many of those patients did perfectly well, and I think that has to do with the fact that the ganglionic bowel, if it's good, can overcome a lot. ↗
▶ Ep 28 · 21:18
clinical Of the four classic procedures (Swenson, Suave, Duhamel, Rabine), only the Swenson actually leaves behind virtually no Hirschsprung tissue. The others leave behind outer rectal wall or original rectum. Many patients did well despite this because ganglionic bowel, if it's good, can overcome a lot. ↗
▶ Ep 28 · 21:18
quote It's fascinating actually that, you know, of those four procedures, the only one that actually leaves behind virtually no Hirschprungs is the Swenson. The suave leaves behind the outer rectal wall. The Duhamel leaves behind the original rectum, and the ravine leaves behind the original rectum as well. Amazingly, many, many of those patients did perfectly well, and I think that has to do with the fact that the ganglionic bowel, if it's good, can overcome a lot. ↗
▶ Ep 28 · 22:19
clinical Dr. Henrys in the Philippines pioneered primary pull-through operations (without initial colostomy) out of necessity because patients would never return to clinic due to social stigma against colostomies. ↗
▶ Ep 28 · 22:19
clinical Dr. Henrys in the Philippines pioneered primary pull-through operations (without initial colostomy) out of necessity because patients would never return to clinic due to social stigma against colostomies. ↗
▶ Ep 28 · 23:21
clinical Keith Jorgeson applied laparoscopic skills to Hirschsprung disease, doing the colonic work laparoscopically with a Suave dissection from above. Luis de la Torre and Jack Langer developed the transanal approach, starting the dissection from below. ↗
▶ Ep 28 · 23:21
clinical Keith Jorgeson applied laparoscopic skills to Hirschsprung disease, doing the colonic work laparoscopically with a Suave dissection from above. Luis de la Torre and Jack Langer developed the transanal approach, starting the dissection from below. ↗
▶ Ep 28 · 25:34
opinion The current preferred approach is a transanal Swenson (full-thickness dissection). It is the purest operation, leaving behind no Hirschsprung except the very bottom just above the dentate line. If you find the right plane, it's elegant and bloodless. ↗
▶ Ep 28 · 25:34
opinion The current preferred approach is a transanal Swenson (full-thickness dissection). It is the purest operation, leaving behind no Hirschsprung except the very bottom just above the dentate line. If you find the right plane, it's elegant and bloodless. ↗
▶ Ep 28 · 25:34
quote I have started to do about 10 years ago, I would say a transanal Swenson. So when you say Swenson, you have to remember that was transabdominal. When you say swab, that was transabdominal. So I think it's appropriate to say. Transanal suave-like or suave plain or transanal Swenson-like or Swenson plane, and I mean by that full thickness. ↗
▶ Ep 28 · 25:34
quote I have started to do about 10 years ago, I would say a transanal Swenson. So when you say Swenson, you have to remember that was transabdominal. When you say swab, that was transabdominal. So I think it's appropriate to say. Transanal suave-like or suave plain or transanal Swenson-like or Swenson plane, and I mean by that full thickness. ↗
▶ Ep 28 · 26:23
clinical Dr. Orvar Swenson, who recently died at age 105, maintained that the Swenson operation was good all along and people just weren't doing it right, which gave it a bad reputation. ↗
▶ Ep 28 · 26:23
quote Dr. Swenson himself, who recently died at the age of, I believe, 105, was a big fan of helping us, help reminding us of how good the Swenson was, because he said, you know, I've been saying the Swenson operation has been good all along. People just weren't doing it right, and it got a bad rap, unfortunately. ↗
▶ Ep 28 · 26:23
quote Dr. Swenson himself, who recently died at the age of, I believe, 105, was a big fan of helping us, help reminding us of how good the Swenson was, because he said, you know, I've been saying the Swenson operation has been good all along. People just weren't doing it right, and it got a bad rap, unfortunately. ↗
▶ Ep 28 · 26:23
clinical Dr. Orvar Swenson, who recently died at age 105, maintained that the Swenson operation was good all along and people just weren't doing it right, which gave it a bad reputation. ↗
▶ Ep 28 · 27:06
clinical Even Suave enthusiasts are making shorter and shorter cuffs over time. Jorgeson's original laparoscopic Suave recommended a 5 cm cuff; nowadays Langer and de la Torre do 1-1.5 cm cuffs, essentially approaching a Swenson. ↗
▶ Ep 28 · 27:06
clinical Even Suave enthusiasts are making shorter and shorter cuffs over time. Jorgeson's original laparoscopic Suave recommended a 5 cm cuff; nowadays Langer and de la Torre do 1-1.5 cm cuffs, essentially approaching a Swenson. ↗
▶ Ep 28 · 28:50
opinion Laparoscopy is appropriate for all cases to find the transition zone level. A transanal-only approach is only appropriate when you have a very reachable, obvious transition zone at mid-sigmoid that you can comfortably reach transanally. ↗
▶ Ep 28 · 28:50
opinion Laparoscopy is appropriate for all cases to find the transition zone level. A transanal-only approach is only appropriate when you have a very reachable, obvious transition zone at mid-sigmoid that you can comfortably reach transanally. ↗
▶ Ep 28 · 29:06
quote I have seen a lot of morbidity that has resulted from an overly aggressive transanal-only approach, um, trying to reach the transition zone with the, with the valiant attempt of never going into the abdomen laparoscopically or via laparotomy, and I think that that is a problem. ↗
▶ Ep 28 · 29:06
quote I have seen a lot of morbidity that has resulted from an overly aggressive transanal-only approach, um, trying to reach the transition zone with the, with the valiant attempt of never going into the abdomen laparoscopically or via laparotomy, and I think that that is a problem. ↗
▶ Ep 28 · 29:18
clinical There is significant morbidity from an overly aggressive transanal-only approach trying to reach the transition zone without going into the abdomen. If you're too aggressive transanally trying to visualize the dissection, you would have been better off with laparoscopic dissection. ↗
▶ Ep 28 · 29:18
clinical There is significant morbidity from an overly aggressive transanal-only approach trying to reach the transition zone without going into the abdomen. If you're too aggressive transanally trying to visualize the dissection, you would have been better off with laparoscopic dissection. ↗
▶ Ep 28 · 31:18
clinical Total colonic Hirschsprung patients present differently: the diagnosis isn't made right away, the contrast study is not typical, and irrigations don't go well. These patients need laparoscopy first to find the biopsy location. ↗
▶ Ep 28 · 31:18
clinical Total colonic Hirschsprung patients present differently: the diagnosis isn't made right away, the contrast study is not typical, and irrigations don't go well. These patients need laparoscopy first to find the biopsy location. ↗
▶ Ep 28 · 32:35
quote If you do a trans anal and you're too aggressive in your attempt to visualize the dissection. You would have been much better off with a lower laparoscopic dissection, no question about it. ↗
▶ Ep 28 · 32:35
quote If you do a trans anal and you're too aggressive in your attempt to visualize the dissection. You would have been much better off with a lower laparoscopic dissection, no question about it. ↗
▶ Ep 28 · 33:55
quote The biggest problem is people don't give themselves good exposure and then they start the dissection too low and they injure the dentate line or resect the dentate line. Or they give themselves very aggressive exposure and they overstretch the sphincters. ↗
▶ Ep 28 · 33:55
quote The biggest problem is people don't give themselves good exposure and then they start the dissection too low and they injure the dentate line or resect the dentate line. Or they give themselves very aggressive exposure and they overstretch the sphincters. ↗
▶ Ep 28 · 34:09
clinical The biggest technical problems are: (1) surgeons don't give themselves good exposure and start dissection too low, injuring or resecting the dentate line, or (2) they give very aggressive exposure and overstretch the sphincters. ↗
▶ Ep 28 · 34:09
clinical The biggest technical problems are: (1) surgeons don't give themselves good exposure and start dissection too low, injuring or resecting the dentate line, or (2) they give very aggressive exposure and overstretch the sphincters. ↗
▶ Ep 28 · 35:30
clinical Proper technique requires marking 1 cm proximal to the dentate line with a purple mark and placing 5-0 silk stitches circumferentially at that level. This preserves the anal canal, dentate line, plus an additional 1 cm of columnar epithelium before starting dissection. ↗
▶ Ep 28 · 35:30
clinical Proper technique requires marking 1 cm proximal to the dentate line with a purple mark and placing 5-0 silk stitches circumferentially at that level. This preserves the anal canal, dentate line, plus an additional 1 cm of columnar epithelium before starting dissection. ↗
▶ Ep 28 · 36:39
quote By definition, you're leaving behind 1 centimeter of columnar epithelium, that of course is Hirschberg's disease, but the ganglionic bowel is able to overcome that. And of course you're leaving behind the smooth muscle, the internal sphincter, which has a problem by definition with relaxation. However, that can be overcome by good ganglionated bowel pushing through and eventually the baby recognizing how to relax that sphincter over time. ↗
▶ Ep 28 · 36:39
quote By definition, you're leaving behind 1 centimeter of columnar epithelium, that of course is Hirschberg's disease, but the ganglionic bowel is able to overcome that. And of course you're leaving behind the smooth muscle, the internal sphincter, which has a problem by definition with relaxation. However, that can be overcome by good ganglionated bowel pushing through and eventually the baby recognizing how to relax that sphincter over time. ↗
▶ Ep 28 · 36:39
clinical By definition, you're leaving behind 1 cm of columnar epithelium that is Hirschsprung disease, plus the internal sphincter which has a problem with relaxation. However, good ganglionic bowel is able to overcome that, and the baby eventually learns to relax the sphincter. ↗
▶ Ep 28 · 36:39
clinical By definition, you're leaving behind 1 cm of columnar epithelium that is Hirschsprung disease, plus the internal sphincter which has a problem with relaxation. However, good ganglionic bowel is able to overcome that, and the baby eventually learns to relax the sphincter. ↗
▶ Ep 28 · 38:19
clinical The rectum doesn't really have a mesentery; the rectum's blood supply is intramural. As you get higher and reach the peritoneal reflection, that's when you start to see sigmoidal vessels where rectum transitions to sigmoid. ↗
▶ Ep 28 · 38:19
clinical The rectum doesn't really have a mesentery; the rectum's blood supply is intramural. As you get higher and reach the peritoneal reflection, that's when you start to see sigmoidal vessels where rectum transitions to sigmoid. ↗
▶ Ep 28 · 38:19
quote The rectum doesn't really have a mesentery. The rectum's blood supply is intramural. ↗
▶ Ep 28 · 38:19
quote The rectum doesn't really have a mesentery. The rectum's blood supply is intramural. ↗
▶ Ep 28 · 38:45
clinical The anterior rectum frees up much quicker than the posterior rectum. Break into the peritoneal reflection anteriorly first. In transanal-only cases, you can pull the sigmoid out anteriorly, do a full-thickness biopsy, and send it while continuing the posterior dissection. ↗
▶ Ep 28 · 38:45
clinical The anterior rectum frees up much quicker than the posterior rectum. Break into the peritoneal reflection anteriorly first. In transanal-only cases, you can pull the sigmoid out anteriorly, do a full-thickness biopsy, and send it while continuing the posterior dissection. ↗
▶ Ep 28 · 40:56
clinical For laparoscopic biopsies through the umbilicus, a seromuscular biopsy (without violating mucosa) may show ganglion cells in the seromuscular layer but miss hypertrophic nerves in the submucosa. If using this technique, send a full-thickness biopsy later to confirm the level is appropriate. ↗
▶ Ep 28 · 40:56
clinical For laparoscopic biopsies through the umbilicus, a seromuscular biopsy (without violating mucosa) may show ganglion cells in the seromuscular layer but miss hypertrophic nerves in the submucosa. If using this technique, send a full-thickness biopsy later to confirm the level is appropriate. ↗
▶ Ep 28 · 44:03
clinical Pathologists must report not only ganglion cells but also the quality of nerves with actual micron measurements. Nerves should be 40 microns or less. Anything bigger than 40 microns is transition zone bowel. ↗
▶ Ep 28 · 44:03
clinical Pathologists must report not only ganglion cells but also the quality of nerves with actual micron measurements. Nerves should be 40 microns or less. Anything bigger than 40 microns is transition zone bowel. ↗
▶ Ep 28 · 44:20
clinical The concept of 'go 5 cm above the transition zone' is inaccurate. Transition zone is a spectrum - some are 10 cm, some are 3 cm. You need confirmatory biopsy with ganglion cell information and nerve quality measured in microns. ↗
▶ Ep 28 · 44:20
clinical The concept of 'go 5 cm above the transition zone' is inaccurate. Transition zone is a spectrum - some are 10 cm, some are 3 cm. You need confirmatory biopsy with ganglion cell information and nerve quality measured in microns. ↗
▶ Ep 28 · 44:20
quote The concept of go 5 centimeters above, and I think that's inaccurate. I think transition zone is a spectrum. I've seen 10 centimeter transition zone. I've seen 3 centimeter transition zones. So you really need a confirmatory biopsy, and your pathologist can. If properly trained, gets you the ganglion cell information and also the quality of the nerves to the to the micron measurement. ↗
▶ Ep 28 · 44:20
quote The concept of go 5 centimeters above, and I think that's inaccurate. I think transition zone is a spectrum. I've seen 10 centimeter transition zone. I've seen 3 centimeter transition zones. So you really need a confirmatory biopsy, and your pathologist can. If properly trained, gets you the ganglion cell information and also the quality of the nerves to the to the micron measurement. ↗
▶ Ep 28 · 45:57
clinical It's preferable to take the IMA, preserve the arcade, and have the left colon and sigmoid nice and straight down into the perineum. This makes for an easy-to-irrigate baby. Many patients have not had enough of a pull-through with the entire sigmoid loop still there, requiring redo to remove more. ↗
▶ Ep 28 · 45:57
clinical It's preferable to take the IMA, preserve the arcade, and have the left colon and sigmoid nice and straight down into the perineum. This makes for an easy-to-irrigate baby. Many patients have not had enough of a pull-through with the entire sigmoid loop still there, requiring redo to remove more. ↗
▶ Ep 28 · 47:02
clinical For anything proximal to the splenic flexure, do colonic biopsies and an ileostomy and wait, because frozen section has been notoriously fraught with errors in those cases. There is no urgency. Another option is to take biopsies, quit without diverting, and return 3-4 days later for pull-through with permanent section results. ↗
▶ Ep 28 · 47:02
clinical For anything proximal to the splenic flexure, do colonic biopsies and an ileostomy and wait, because frozen section has been notoriously fraught with errors in those cases. There is no urgency. Another option is to take biopsies, quit without diverting, and return 3-4 days later for pull-through with permanent section results. ↗
▶ Ep 28 · 53:16
quote I am passionately committed to not have a baby come back. And readmitted with enterocolitis, and I, what I will do is I will wait until the belly is absolutely soft and flat. They're having bowel function, passing gas, stooling. I actually will get an X-ray because I think abdominal distention is sometimes subclinical, and I don't feed that baby until the X-ray looks good and the belly's flat, and that usually takes 3 or 4 days. ↗
▶ Ep 28 · 53:16
quote I am passionately committed to not have a baby come back. And readmitted with enterocolitis, and I, what I will do is I will wait until the belly is absolutely soft and flat. They're having bowel function, passing gas, stooling. I actually will get an X-ray because I think abdominal distention is sometimes subclinical, and I don't feed that baby until the X-ray looks good and the belly's flat, and that usually takes 3 or 4 days. ↗
▶ Ep 28 · 53:23
clinical Postoperatively, wait until the belly is absolutely soft and flat with bowel function before feeding. Get an X-ray because abdominal distention is sometimes subclinical. This usually takes 3-4 days. Feeding too early risks the baby going home distended and returning with enterocolitis. ↗
▶ Ep 28 · 53:23
clinical Postoperatively, wait until the belly is absolutely soft and flat with bowel function before feeding. Get an X-ray because abdominal distention is sometimes subclinical. This usually takes 3-4 days. Feeding too early risks the baby going home distended and returning with enterocolitis. ↗
▶ Ep 28 · 54:39
clinical Routine postoperative management: at one month, check the anus with Hagar dilators (not finger). Most babies need calibration rather than true dilation. The stimulation of passing the Hagar has value to help the baby more successfully empty. ↗
▶ Ep 28 · 54:39
clinical Routine postoperative management: at one month, check the anus with Hagar dilators (not finger). Most babies need calibration rather than true dilation. The stimulation of passing the Hagar has value to help the baby more successfully empty. ↗
▶ Ep 28 · 55:52
clinical Flagyl is only used to treat enterocolitis, not routinely postoperatively. Give a pre-op dose of second-generation cephalosporin and maybe 2 post-op doses. ↗
▶ Ep 28 · 55:52
clinical Flagyl is only used to treat enterocolitis, not routinely postoperatively. Give a pre-op dose of second-generation cephalosporin and maybe 2 post-op doses. ↗
▶ Ep 28 · 56:31
clinical Routine irrigations are only done postoperatively if the baby develops significant distention, which is rare. However, for total colonic patients after ileoanal pull-through, send all patients home on irrigations for 3 months. ↗
▶ Ep 28 · 56:31
clinical Routine irrigations are only done postoperatively if the baby develops significant distention, which is rare. However, for total colonic patients after ileoanal pull-through, send all patients home on irrigations for 3 months. ↗
▶ Ep 28 · 57:05
clinical For hepatic flexure transition zone (rare), open the patient rather than laparoscopy. Take down the entire right colon, recognize the ileocolic vessel and how it feeds the vessel paralleling the right colon. Often need to take the right colic artery. De-rotate the colon so cecum is at the hepatic liver bed, then do pull-through down the right side of abdomen. ↗
▶ Ep 28 · 57:05
clinical For hepatic flexure transition zone (rare), open the patient rather than laparoscopy. Take down the entire right colon, recognize the ileocolic vessel and how it feeds the vessel paralleling the right colon. Often need to take the right colic artery. De-rotate the colon so cecum is at the hepatic liver bed, then do pull-through down the right side of abdomen. ↗
▶ Ep 28 · 58:02
clinical If bringing de-rotated colon down the left side of abdomen, must mobilize the ligament of Treitz so the mesenteric vessel is not draped across the third portion of duodenum, which can cause duodenal obstruction. ↗
▶ Ep 28 · 58:02
clinical If bringing de-rotated colon down the left side of abdomen, must mobilize the ligament of Treitz so the mesenteric vessel is not draped across the third portion of duodenum, which can cause duodenal obstruction. ↗

Cloaca Management with Dr. Marc Levitt & Dr. Aaron Garrison

▶ Ep 31 · 2:38
clinical The most common prenatal ultrasound finding in cloaca is a pelvic mass, often initially thought to be the bladder but actually representing a dilated vagina (hydrocolpos). ↗
▶ Ep 31 · 2:38
clinical The most common prenatal ultrasound finding in cloaca is a pelvic mass, often initially thought to be the bladder but actually representing a dilated vagina (hydrocolpos). ↗
▶ Ep 31 · 3:59
clinical Fetal intervention for cloaca is unlikely but may be necessary for massive hydronephrosis with impending renal loss; one case report from Japan described hydrocolpos drainage similar to bladder drainage for urethral valves. ↗

Complications of Anorectal Malformations with Dr. Marc Levitt

▶ Ep 32 · 2:57
clinical Anorectal malformations are commonly not properly diagnosed or completely missed in the newborn period. ↗
▶ Ep 32 · 3:06
clinical Male babies with perineal fistula may pass meconium and have the malformation go unnoticed, typically presenting in the first year of life with severe constipation. ↗
▶ Ep 32 · 3:26
clinical In perineal fistula, the hole is too small and anterior to the center of the sphincters, causing the rectum and sigmoid to dilate as stool passes through a tiny fistulous orifice. ↗