Cloacal Exstrophy Repair
Anesthesia (not shown): GA in OR with Peripheral and Central LinesVIDEO:
- Draping and Planning
- Mobilize Omphalocele and Ligate Umbilical Vessels
- Establish Plane between Cecal Plate and Rectus Sheath
- Identification of Bladder and Testicles
- Identification of Hindgut and Future Stoma
3. Therapeutic Interventions
- Closure of Cecal Plate
- Reduce Bowel
- Dissection to Identify Corpora
- Division of Urogenital Diaphragm
- Placement of Ureteral Catheters
- Creation of Neo-urethra and Reassessment
- Ostomy creation (not shown in this video)
- Mobilization of Corporal Bodies
- Place and Suture Malecot Suprapubic Catheter
- Closure of Bladder
- Placement of Pubic Symphyseal Stitch
4. Closure of Abdominal Defect
5. Leg Casting of Pelvic Osteotomies
TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarantee their complete accuracy.
My name is call Carl Christian Jackson I'm a pediatric surgeon at floating Hospital for Children Tufts Medical Center and we’re going to be taking care of baby today with cloacal exstrophy. The twin had no congenital abnormalities but on prenatal ultrasounds, cloacal exstrophy with associated myelomeningocele was identified in this baby and today we're taking a multidisciplinary approach to addressing the cloacal exstrophy. Our first goal with the surgery is to free up the intestine from the belly wall. With the exstrophy, the abdominal wall did not close normally so the intestines and bladder are exposed and are attached to the rim of muscle and skin. So we want to separate those so that we can then identify what is intestine and what is bladder. So our first goal after freeing up what's called the cecal plate peripherally is then to separate the cecum and the cecal plate from the bladder plate and then put those together with stitches to make it into a nice tube again, because right now it's splayed open. So we want to get that back into a tube and then eventually form that into an ostomy. So that will come out somewhere on the belly so when the baby stools, it will come out here as opposed to the bottom and that will be the first part and as a component of that will be Dr. Wiygul intimately involved with us in freeing up the bladder, identifying the ureters to make sure that those are protected and not injured and that'll be sort of the initial phase. The next step will be assessing whether or not to do the pelvic osteotomy where the pelvis is broken in a controlled fashion to then try to rotate it. Right now the pelvis should be a ring. Right now it's wide open and then the osteotomies can help free things up so you can bring the pelvis back together to create a normal ring. So the overall goal sounds fairly straightforward and short but the very time-consuming and delicate part of this is to identify all the structures so that nothing is damaged that we can get the anatomy back to an a functional result and there will be staged operations, probably further operations, in the next several months and years to try to get the baby back to his as optimal state as possible.
In classic cloacal exstrophy, you have an omphalocele which is this area here, this yellowish area here, and then you have what is prolapsed terminal ileum coming this way -- that's what's what's on prenatal ultrasound identified as the elephant trunk, and then you have the cecal plate here. And you'll notice that the patient does not have a belt does not have an umbilicus. In bladder exstrophy where the GI system is not involved, you have an umbilicus but it is actually low set and that's actually removed during the course of the surgery and a new umbilicus is created. What we believe we're seeing is actually the hind gut that will be in continuity with the cecal plate here and will be mobilized during the course of the surgery and then with the related GU defects you have split hemiscrotum and then potentially a rudimentary phallus here that is covered by what appears to be urethral plate. As part of the OEIS syndrome which is the omphalocele exstrophy imperforate anus and skeletal defects syndrome which is what this child has, the associated a skeletal defects tend to be clubbed feet, and as you can see there’s no anus. And in addition, coming off the side here is a very large covered myelomeningocele. That means the actual neural components are not exposed to air in there, it's covered by skin. If this was not covered by skin this would actually be the first defect that was closed for this child. And then also because these children tend to have very large, widely spaced pubic ramii, that's the ring of the pelvis, you can actually feel them here where my two thumbs are and what we will do is create pelvic osteotomy to allow sort of inward hinging of the of the pelvis so that we can close the pelvic ring. It's actually very important, that is a crucial step in this operation, because if you do not close a pelvic ring without tension that increases the chances of dehiscence of the wound and extrusion of the bladder.
Bilateral ureteral catheterization, closure of cloacal exstrophy defect and omphalocele and osteotomy. It reduces nicely. It does, it does. I kind of want to drape him from the knees down if we can just sort of cover things try to minimize the bacteria. Okay. Okay so this is our cecum. I think the cecum’s out to here. Ya, I think bladder probably comes -- there. Yep. And then, to presumed ureteral orifices -- oh actually I think this --. I think, I think, I think we might be swinging out this far too, you see that? Yep. Yep. All that looks like bladder plate to me. And how about inferiorly? That’s hindgut, I think, and then right above here is bladder neck right there. You see what I am saying? So, but I think once we start the dissectional release a little bit more. Once you do a circumferential dissection, probably start laterally where we know we are safe, come around --. I think, go in through the omphalocele. Right, ya ya. And then coming down laterally. And then we can see what we got.
So now we’re going to mark out his umbilicus, you go off of the anterior superior iliac spine. So I’ve got the bowel underneath. There we go, we’re in. You want to put a RayTech in there or are you comfortable with this? It’s fine. Whatever you want to do. [incomprensible] I told us were in intra-abdominal that's for sure. Now we're just freeing up the junction between the omphalocele and the bowel with the native healthy skin and can follow that ridge and that normal intestine popping out at us that we do not want to injure. Now this is clearly one of the differences between cloacal and bladder exstrophy we spend all our time trying to stay out of the peritoneum in the bladder exstrophy cases. It’s sort of impossible here, obviously. These are the umbilical vessels, correct? Yes. So presumably this is going to be the umbilical vein. There, and now you see the lumen of the vein. In an adult you could leave these bleeders alone, you’re not worried about them as much, but in a 6 day old infant, we take all bleeding seriously. So I wouldn’t go -- see where my finger is? Don’t go any further, yeah. You can see right here. Oh okay, we’re starting to see the backside. Actually so there, there’s liver and gallbladder.
So there’s appendix right there, and you can see that it’s attached to these two orifici that we were thinking were perhaps the ureteral orifices. And if you look here based on the vasculature, I think this is bowel wall and I think this is peritoneum so I think that is our demarcation line. Mmm-hmm, right along the line of the omphalocele. We’re getting into tiger country over here I think. So that, I’m not sure what that is, but I’d like to avoid it. Sure, let me take a feel here real quick. Running up this way are his vessels. This thing here kind of feels like a testicle, or it could be his umm -- whatever this thing. We can get this out right? Ya, whatever this is I’ve got it on my finger so you’re far away there. Sure, this is umm, right, uhhhh. Do you want to just clamp and tie this? Sure. There is a potential there was a vessel here. Specimen. That actually could be a hernia we’re feeling actually, now that I think about it. What are you calling this? We’re calling that uhh…umbilical stump. Right umbilical stump. Okay so we’ve mobilized that there. Ya, I think the bladder is way down here. Yeah. Actually that, uhh, here we can try to get that. Right on the other side. So actually because this, yes. I can take this off on this side. Actually I was saying before you -- cut it there first. Can I see that? Yeah. You can probably cut through this. Yeah I think you’re clear there. And here we just need to be cautious -- that vessel runs. There’s vessels down there, something’s down there. That’s all free. So if we cheat here, is there anything there that we have to worry about? That feels like a vessel there. So I think we should be able to come here -- no, I think that’s your cut vessel. Yeah, no but I think that’s uhh -- what’s going where? Because if this is our umbilical vein then that’s fine we just come all the way across that. I’ll take it -- I got it. Old clot. I think you’re good. Can you see on that side? There we go. So I’m coming from this way? I would agree with that. Now that’s just peeling away, that’s a good sign. Just walk towards the top, towards the top. Sure. You want to come on the other side then? You want to flip it this way now? So, alright now we’re starting to see something here, okay. There we are, now you can see -- now this is starting to look -- The left side, like the opposite side. I’m looking at the computer. So that’s cecal plate right there. And where the hell is the bladder? So here’s appendix, that looks like one and I think we had a second one didn’t we? Yeah, second one is on the other side. There, right there. Yep. So we have two which is very common. Is this the bladder?
No I don’t think so, I think we need to release here a little bit. It’s coming from below. What I think is happening is we have a bladder plate which is sitting down like this, and then the cecal plate kind of starts off behind it like that. That seems like that’s bladder down there. So obviously making some sort of urine, so. So what I think I’d like to do is mobilize this a little bit more and just see if we can get things to pop up and then just by virtue of pulling up maybe we can see if we can see a little bit more. Right angle? Right here. Yeah, that looks good. I don’t have great dissection there, there’s not really a good plane. I don’t know if you can see better? No I’m just trying to think about what we would be running into here. I’ll take it like this. That looks like testicle right there. That looks like a testicle -- that is a testicle. Well I don’t want to be down there because there’s literally, there could be all sorts of things down there. I think I just wasn’t --. You’re saying with testicle, that we can come lateral? Can we -- No we can get in here. Is that going to give you trouble or is it better just to kind of leave it umm--- Well I’m just wondering what exactly we’re doing with it. Like how are we -- Just, is that going to give us any exposure if we’re going to take that laterally and take this down? Does that help us or no? No I don’t think so, this is attaching into here. The problem is that we need to really have this up so I can see what’s below it. That’s the issue.
I can see the hindgut, and try to free the hindgut from the inside? So that’s all in continuity right? So that’s got to all be gut right? So we said cecal plate central, bladder plate lateral? Lateral. So does he just not have a bladder plate then? I guess that’s a possibility. But we know he’s making urine right? Right, like otherwise, his ureters have got to be going somewhere because he has normal looking kidneys so he’s got to have ureters entering someplace. It looks like they’re coming down here. Let’s see. So, this to me what I’m seeing here, is like sort of the limit to the cecal plate here. You agreeing with that? There’s certainly a transition there. Yeah. I’m wondering if we can get into that plane and sort of, get into the peritoneum, underneath the peritoneum, and see if we can bring that down. I mean, everything inside of this has to be cecum, correct? Unless we, is there, can we have an ectopic bladder inside of a cecum?
Where’s the ureters? So like I think this, right can I have a pickup? That’s cecum, that’s cecum, that’s bowel, that’s bowel. But where does this bowel go? Like that’s hindgut. That’s hindgut? That’s hindgut, because that’s foregut. Yeah, this is hindgut, this is my finger going down the hindgut. Can we do this? Yep. Yep. Ok, does that help with my finger in there? I’m not sure. So if that’s mesentery, because that looks like mesentery there. So I think we want to get into that space right there. Yeah because that is appendix right there so we can probably come into this. So actually let’s trace mesentery here. You got that? That’s mesentery, that’s mesentery. How about from that side? Because this is, is that mesentery or just some stuff? That’s some stuff. Just some stuff. Yep, there we see some mesentery, okay -- yep. So I think this can probably come down that looks like -- Yeah I think once we get this fully mobilized it’ll give me a better idea here. We basically just splay out the bowel so we know what’s what. Looks a little thick there. There’s -- that’s mesentery there I think. Mesentery. So that’s mesentery coming this way, which means that this should be anti-mesenteric if we wanted to take it -- Run along this way? But we don’t know what that is. But we don’t know what’s what, yet. I think there’s a plane we can get into above this. But I think that if this is showing this a little better, this looks like cecum and that may be division there. Bladder?
Could be bladder here. We have cecal plate centrally, ureter coming, you know the bladder plate laterally. Because we could, potentially we cut this, because the cecum comes here and the hindgut goes there and then this is cecum and then the rest, whatever, down there is bladder. Yeah, you’re right, you’re probably right. So part of this is bladder probably. I’m thinking because you can see the cecum, and then there’s a transition. And as, you know, could that be why we had some -- although we didn’t really cut in there but you know could this be bleeding because we’re coming across? This actually could be ureter coming in through here. What do you want, do you want to canalize? Well I can’t find the UO yet. That certainly looks like a UO but...grab close to me. I got it, I’m supporting it. Ah I think it is just curling up. It looks like it’s in there. Or is it just because it’s on the back side of it? Let’s try this again. Now I’m starting to see this -- I think this is bladder right here, you see this? Bladder, bowel? Yep I think that’s what we’re seeing now. We can see it a bit more clearly. That trabeculated stuff, that’s going to come down? Yep, yep. So I think this is -- yeah I can see it a bit more clearly now. And what is -- so that’s going to be a part of the bladder right across there? Yeah because these are trabeculated -- striated fibers that come with the -- or sort of criss crossing fibers that come with the bladder.
If we had to we could cheat a little bit here to leave you, so we know we are not -- taking more than you need to. But let’s confirm where the hindgut is, obviously, before we do that. I think that’s -- the hindgut is here. Yeah, so it’s above where i’m holding, I think. Yeah, so this -- hold on one second. Yeah, this is all bladder down here I’m almost positive of it now. All this is here, and then the hindgut is up this way. Yep, you can see that. Yep, this bladder mucosa looks very thin and attenuated so we just got to be aware of it.
Here is -- this is hindgut going this way, so i’m thinking like across like this. Let’s make sure we’re clear on the backside, there. Make sure the testicle is down. So I’m going to come across here? Yeah that looks good, yep. Not much of a bladder, not much of a bladder. So that’s bladder right there, see that? Now it’s starting to look like something real. Now, we’re getting into gut there I think. Maybe we should go a little more superficial? Yeah, why don’t you go superficial and we can go by layer, what do you think? DeBakey, please. So I’m going to come across here? Yep, I agree with that. Okay, just to show everyone, hindgut coming this way, cecal plate here, presumptive bladder right here, and we’re separating the two. Here’s our ileum coming to cecal plate, we’ve got one appendix there, we have our other appendix -- ah here. So that seems relatively free, I think. I mean this is testicle here, actually if we want, we can just sort of tuck it away. Is that the end here? I think you’re right, because there’s mesentery, yeah, there’s gut -- I don’t know what that is. I don’t think we need to take it, is our blind end. And that’s what you’ll bring up? That’s what we’ll bring up.
Alright so let’s take another look at this. So actually there is our gut, small bowel, now we need to -- cecal plate, our two appendiceal tips, and heading down into hindgut. Heading into hindgut that way. Actually we could probably take that mucosal ridge there. If we start here, this is anti-mesenteric here, that’s lined up. If we run that up -- and this -- a little of this that we can freshen up, this is your omphalocele. That’s true, we can just cut across a little bit here. Okay. That should be my fingers right there. Yeah. This is the end of the bowel right here, and this will be the part that becomes the stoma.
This is cecum, this is large bowel. Okay setting it up here. And did you want to address that? So now we’re closing the cecum, that part of the bowel that we saw at the beginning of the case that looked like an elephant trunk is actually this part right here that has now been everted back into its normal position and we’re closing the plate. I’m thinking we imbricate that little bit. DeBakey. Actually Gerald if you got it. You want me to imbricate where? This part? Yeah. I was always taught interrupted, one of the guys I worked with who trained in Argentina, they did everything running. Probably doesn’t make a bit of difference as long as you have good technique for your apposition.
We’re almost done with closing the cecal plate, and Jeremy is up for the bladder component and I think we’ll probably do the ostomy at the end. Is that how you want to do it? Yeah sounds good because once you make the ostomy you don’t want to be tethered and all that stuff and then the exposure -- yeah you can move the bowel out of the way. Should we keep the skin on antibiotics? Probably at least 48 hours. 48 hours. Scissors please. Below. Cecal plate is now closed. Show that. Cecal plate there, okay. Can I do this for you guys? Yeah, and you can actually -- what’s even better would be to tuck some of that back in. Okay. Pushing it up. You have the, umm, peanut? Taa-daa. If you want to see, here’s our fascial defect at the end. It’s a small omphalocele -- that’s relatively small.
Floor. So I think that’s -- yeah that’s all corporal tissue right there. Take a Bovie and just buzz right between my uhh -- Starting here and then where do you want to end up? I would just come down to here and then we’re just going to dissect from there. Okay. There’s a lot of stuff not making sense about this and now I’m starting to understand it a bit better. Do you have an adson for Dr. Wiygul? Ah here, you can buzz through the skin now, you’re safe. Yep. Good. Those look like corpora. There you go. Yep yep yep. So where do you see corpora? Right here. Ah there’s one. That looks like corpora right there. Okay buzz in the middle here a little more, release that. Coming right there? Yep yep yep. As long as you’re in the midline you’re safe -- okay, stop. Let’s see here. That right here. That’s just a blind ending bladder. So that should be -- would you then --. What I want to do, is detach this and bring it up. Detach all this and bring it up so that it is draining onto the uhh -- onto this. And what I can do is, I can detach it from wherever it is tethered here and then anastomose it to the skin here and that way you’ve at least got a urethral opening draining low and then you bring the pelvic bones over the top. So let’s say it’s coming down like this to a point, right? The bladder is blind ending right here. You detach it, you bring it up, and then you sew the back end back to the skin. But we need to identify the corpora a little bit more so we know what our lateral extents are. The problem is we don’t have any actual urethra. Yeah I think you’re bringing them open in line 2. No I’m meaning to, yep.
Retract the air a little bit for me? Can you retract -- yeah perfect. Careful here. Where’s the bone? So we’re right on bone right there that’s -- I’m right on top of the pubic bone if you can feel right there. So we’re dissecting some of this off so we got to be careful. That’s corpora right there -- the left corpora -- yeah and it’s coming this way. And traditionally, this is where the intrasymphyseal bands are, but you can define a little bit better because you can see where the bladder neck is and you can go lateral to that and you actually retract the pubic bone. Got to find that pubic bone, it’s right here actually. Right here. Okay so here’s bladder, actually getting around the backside there aren’t we? Let’s think about this, does this make sense to do this? Here’s corpora you can clearly see that. Umm, tenotomies? So the reason why I’m even messing with the corpora is that they -- if I can follow it down, then I know where I am in terms of this dissection. Okay. And I’m not just sort of blindly cutting. See, all of this needs to go, this stuff here. Yep. And you can actually -- that looks like corpora here coming down like this. It’s coming from behind. Starting down that way. Coming across here. It’s actually becoming much clearer now, you see that? Yeah. And I think if we stay on this side --. I know this seems sort of gratuitous, but this is actually really going to be able to let me define the anatomy a lot more, and especially since this is not run-of-the-mill stuff. Let’s go and feel where the pubic bone is there yeah I have to take these down. Over here. Actually by doing this, I can potentially give him a little bit more penile length too. What I’m trying to understand is what this tissue is. So this is bladder neck, or looks like what would have been bladder neck. And then this is suspensory ligament here. Very good. Umm, and then we have this tethering here, just want to make sure. Can I have the Bovie? Good that’s perfect. And the other? Yeah so we’re coming right up on the pubic bone on that side too. You see how this dissection lets me see where the corpora is and makes sure I’m not doing anything terribly stupid? Another Babcock please. Got it. I just want to be gentle with as much of the bladder as possible so we’re not renting things. Okay, and come in here again. That is where we need to be right there. So let’s get a hook. Feel the bone? It’s right here. Right here, right here. And get on that and retract. Bone there. This is bone right here. That’s periosteum that’s why it was bleeding into ---. You’ve got to be careful, because if you go any further that way and it’s corpora and that’s a very hard thing to stop to bleed. Let’s see here.
It’s a little more easy with this part, just so you guys know. I feel like we should be there. This is pubic bone right here. Take a feel, you can feel that and feel that there’s a band sort of still there. You see what I’m saying? So that’s the problem. There’s the pubic bone right there, I think we can do a little bit more right there. Am I going to be able to drop that in? Can you hold it like that, just gently, obviously? Yeah. So it’s clear on this side I feel like. But this right here is the problem. That’s where you have suture? Yep yep. So I think I need to be here. You’re just kind of riding the pubis? Exactly. Right on top of it right there. So I think that, we can definitely get over that’s far enough there. Let’s look over here again. And the question is are we far enough over here? Don’t think so that’s totally different, just completely different. The bladder is not free from the side walls. Yeah so this is right -- here’s the pubic bone right there. That’s periosteum I’m on right now. That’s a vessel right there. Put your pickups on that again, I’m Boviting. Okay go ahead. Just above it. Alright so I think that was a good blow there, yeah I feel like we’re pretty close. Now we may need to take that down a little bit more. Corpora is running here and I think we can come here. That’s just fat right there. Okay, so this is bladder neck here. So there’s the pelvic floor there. Come this way a little bit. Now, the issue is look how thick this actual bladder neck is, and we got to be able to drop this down and bring this over the top of it. I think we can do that. And then so where is the urethra going to come out? He’s got no urethra. What ever urethra we create for him will have to be a neo-urethra so from skin or something like that. So what we’ll need to do is close the bladder, we’ll put a separate SP in, then I’ll put the pubic stitch in, bring the symphysis together and then you guys can close. Okay.
This would make things a lot nice for him. So, where is urethra? Urethra should be deep to the corpora right? Yeah, but in these cases they’re usually shallow, there’s usually an epispadias but I’m starting to feel like all bets are off on this kid. Sometimes it’s better to be lucky than good. Okay. That’s one in. Okay can I get a 5-0 of chromic please. Now the issue here is normally I would drain these to separate bags, but because I’m going to have to bring it down through this neo-urethra, I’m going to have to cut these off more than likely. Do you want to mark it in some way, right and left? Yeah, yeah we’ll definitely do that but I’m just thinking in terms of being able to drain things. So UO should be over here somewhere. So let’s see where the other one is. That’s a strange place to have another UO. It’s going nowhere. You can try it but I don’t think it’s going to make a huge difference. Will it allow you to see at all? Normally you can’t really see it that way. Alright, come back again. I’m afraid we’re ripping his bladder so much too. I don’t want to go too crazy with it. We’ve got one in so we know he’s going to be drained, so I’m thinking maybe we need to cut our losses here. And if you had to do a nephrostomy? Yeah you could. Okay so let’s look, what do we got? Alright so here’s this. We got that so that’s bladder neck. We really don’t want get that more than we already have so we can bring that together, and now we’re going to do this neo-urethra. Okay.
So typically with this defect, you have a urethral plate that you close. It actually appears that he has a urethra extending down under his corporal bodies and we’re going to basically do something like a cut to the light procedure here to see if we can get something to anastomose to the skin. Is this all just urethra? No this is corpora. This is corpora up here. Bovie. Push. All right. Actually we might be able to get this through. Okay. Let me see a 5-0 vicryl? So what I would do is, I put a stitch in here, this is like the everted ileum right? Yeah. So we push it back in and I’ve got a stitch on the other side that I can pull through and that averts the mucosa. But your concern is correct because it looks like the defect is actually through Buck’s fascia rather than through -- it’s like we came through the ventral aspect of the urethra -- right exactly. Yeah right here is the defect. You can close that up. Yeah yeah yeah. What about the intraperitoneal injury? Do you just loosely close it and it’ll heal on its own? This? This injury isn’t a big deal at all, this is actually more just mucosa than anything else. We actually just undermined the mucosa here, that I’m looking at it. No it should be fine. What I’m thinking is, can we burrow through there on this and cut through it like that way. It seems like that’s all fibrotic. I’m already through. I’m not seeing our lumen here. Right. Or are you just thinking that tip there? I’m not going to do anything more to this, I’m going to close the bladder and put an SP tube in and that’ll be it and I’ll bring this out through a separate stab incision or something along those lines. At this point I’m afraid -- he’s already been on the table for a long time and I don’t want to keep trying to make this happen. We can always come back another day and do it.
Close this bladder real quick, we won’t close the whole thing, we’ll get it started but you guys don’t want me to put the SP tube in, right? Right, because we’ll do our ostomy. Should we do our ostomy now? Sure. Or do you want to get some of that closed? It doesn’t matter, you guys go ahead. Then you can do whatever you need down there. Right exactly, I’ll do a little bit more to the penis. What I’ve got to do is I’ve got to cover the penis, close the bladder, put in an SP tube, and then bring the pelvis together.
So what I’ve done is I’ve brought the ends of the corporal bodies, which are the erectile tissue, up so it can potentially be stimulated in the future when he gets older so he can potentially achieve orgasm, but the problem is it is covered -- it’s obviously very raw looking and my concern is leaving it like this. Is it going to scar in some way that’s going to make him unhappy or even worse, reduce the sensation? That was probably one stitch too much. Yeah probably so. Scissors please. We’ve got to keep that open until we put the pubic symphysis stitch in. Okay so let’s have a right angle clamp. Okay. Problem with that is this is the side of the bladder that’s more of a problem, but we can still bring it in this way. Let’s see here. Bovie. There’s not much of a space there for that bladder. You want this out? We’re going to bring that through a separate stab incision as well. Unfortunately, I have to draw this across -- I have this intraperitoneal this way, I mean it’s not the biggest deal in the world, I’d like to keep it extraperitoneal if you can but -- yeah. I mean we take out drains intraperitoneally all the time but, just so you know. Okay so there’s that. So you’re not going to bring that one up through your umbilicoplasty? This? No because like I said, I want to keep this in for a period of time and if we go through the umbilicus it’s going to be hard to -- let that heal -- yeah exactly.
So let’s do this, we got to bring this through too. Let me have the right angle back? Cut the end of that one then? Yep. Bovie. Actually, let’s do it this way. I think I should be able to get that through. 5-0 vicryl please? Sewn in in standard fashion. Do you have the malecot stitched in there as well? Yeah I’ve got a purse string around it right now, so yeah. Oh okay I wasn’t sure if you had anything internal as well. Oh, no no no. I haven’t stitched it into the bladder. I sure don’t want to sacrifice any more bladder than I have to. Sure. Let’s see if we can make this work like this. Can I get a syringe? I just want to flush this real quick to make sure we don’t have any giant leaks here. Sure, yeah why not? You’re trying to flush this? Yep. Okay, great. Go ahead. Don’t cut it yet, but I want you to irrigate. That’s the reason why you do it. A little bit of a chimney here. Trying to preserve as much bladder as possible. This is a decent sized bladder, especially for a cloacal exstrophy patient. Just gently though. It’s right here. Alright, so those tiny ones are not -- irrigate again. He had a pretty severe myelomeningocele and chiari malformation so. Something’s leaking low. Can you fill this up again? We’re at the sixth hour.
It’s not a full length, okay? That’s fine. One more time, gently. Pickups. That looks pretty dry. So this is where we’re going to put the stitch in and then we’re going to adduct his legs. You want to take the IO band off? Yeah, we do. In actually we can take a quick look at the myelomeningocele part of the -- does that look ok? Can you retract there for me? That’s not going through corpora, right? No, corpora is over here. There’s one. Now the other side now. Now those are some pretty good bites there so. So I’m going to start tying down, can you just light that first? It is, this is the pubic symphysis stitch. This is what we call a number 2. Take that out? Yeah, go ahead. So slowly bring the hips closer together. Not so much, not so much, there we go. Can you snap that knot? Mosquito? Ok we’re good. If we can get this to hold I think we’ll be set. Actually what we can do is we’ll cover it with xeroform, yeah. I can do a bunch of stitches, because it does slip. A bunch of knots you mean? Yeah, I’ll usually do like 6. Did it work? We’ll see. Let go. It’s not perfectly opposed, yeah they’re right next to each other so I think we’re okay. I think we’re okay. No we’ll stick with it for now, let’s go ahead and close this. Yeah you can feel the tips are right next to each other there.
Skin hooks, and I’ll take an adson with. Another skin hook. With a Bovie. What we’re doing here is separating the skin from the fascia so we can get a nice muscular closure. Nothing important there? Yeah, you’re good. I think all the way around you’ll be fine. The bladder’s deep in the pelvis now. That’s pretty good there, we’ll see. Let’s see how we’re doing. I think as far as muscular closure -- that’s fascia there and down here we’re kind of below, and that’s bladder. Here and below is bladder neck so, and that’s the pubic bone right there, so I don’t think you’re going to -- so we can close the fascia here and what I’m thinking is we’ll do some interrupteds and you can see how this comes together. We’re closing the fascia now. Hopefully it stays together. I think the pelvic osteotomies were definitely key. And actually ethibond seemed to be a nice stitch for that. Yeah. So as we get a little bit lower, we’ll have to see what’s muscle. The bladder’s pretty far down, that’s bladder right there so you’re good. So that’s bladder there? Below it, but you’re good up there. Okay. If you just want to be in there you’re fine. It’s okay there right? Yeah. Another stitch? Do we have some more 5-0 vicryl because I’m going to have to do a couple more things down low. So now here is where we kind of get into this and this is where -- actually what I can do is I can define this for you right now. Let me see that 5-0. I’m guessing that, actually I’m coming this over to there. Right, and this goes down, this can come over. This can all come like here. That’s bladder right? Well but you’re on top of it -- not really because this is up here is fine and I think you can bring that to there. Bovie. I just want to free up a little bit there because I think when you pull that up, let’s show that. And then this stuff you can bring over. So as far as muscle -- I’m just trying to think and see what we have as far as muscular wise. We’re clear right there, we’re clear all the way up to here basically. But I need to use this skin to resurface down there so. Okay so you don’t want me to take that, but I can take, and what is this here? Below that? Oh that’s the umbilical artery. Okay. Yep. That’s right. So I can come like that. So then that’s bladder there. You’re not incorporating bladder. What I’d like to do is see if I can get -- that stuff? Yeah I think that makes sense. So then I can bring this. I think you can take all of that. Snap scissors. That looks pretty good, I don’t know if I need to do another one beyond that. Because I don’t want it to herniate down low, but I guess the worst case -- his bladder is there right? So I think this muscle is closed, the bladder is here, yeah I don’t think he is going to herniate down that way. Good. You got this DeBakey? Pull that way and that way? Good. Looks pretty darn good, all things considered.
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