Posterior Surgical Repair of Bulbar Urethral Fistula | Cincinnati Children's скачать в хорошем качестве

Posterior Surgical Repair of Bulbar Urethral Fistula | Cincinnati Children's

http://www.cincinnatichildrens.org medical animation: Posterior Surgical Repair of Bulbar Urethral Fistula | Cincinnati Children's We are looking now at the posterior aspect of the operation. The head of the patient is in the upper part of the screen, and the rectum can be shown here, after we divided all the structures located behind the rectum. This is a rectal bulbar urethral fistula. The rectum should be opened in the midline, with traction sutures placed on the edges of the bowel. At the bottom of the rectum, you can see the recto-bulbar urethral fistula. Fine silk sutures are placed around the urethral fistula and then we begin dissecting, first laterally and then on the anterior aspect. Here, we’ve divided the fistula in a submucosal plane, between the previously placed traction stitches and the fistula opening. And now continuing to perform the dissection in small increments to create two walls where there currently is only wall. At this point, there is still a shared wall between the urethra and the posterior—sorry—anterior aspect of the rectum. It’s important to keep this dissection plane in the submucosal plane to avoid injury to the urethra. This dissection continues until the urethra and the rectum are two completely separate structures. The traction stitch that was placed to identify the fistula is removed and the opening to the urethra is closed with multiple absorbable sutures. We now continue mobilization of the rectum, so that it will reach to the sphincters. Again, carefully dividing blood vessels on the wall of the rectum, in order to gain length. This is performed until there is adequate length for the rectum to reach the perineum without tension. The rectum is now able to easily reach to the perineum with no tension. The perineal body is now closed, anterior to the sphincter complex with multiple layers of absorbable sutures. The rectum is then positioned in the sphincter complex and the posterior incision is closed in layers up to the posterior limit of the sphincter. This is again performed using absorbable suture. It is important to close this incision in layers to avoid creation of a large dead space. The skin is then closed, with multiple simple absorbable sutures on the skin. Now with focus to the creation of the anoplasty. The rectum is split, anteriorly and posteriorly. A u-type stitch is placed from the skin in and out through the bowel and out through the skin at 12 and 6 o’clock. The excess rectal tissue is then excised. Typically this is done halfway across the bowel and placing stitches at 3 and 9 o’clock. Then we continue to place multiple long-term absorbable sutures, evenly spaced, circumferentially around the anoplasty. The sutures are then cut and the anus will be seen to retract into the gluteal cleft, at the conclusion of the operation as seen here.