Surgical repair of traumatic cloaca

Abstract

A 30-year-old female presented to our colorectal clinic with incontinence to solid and liquid stool. During her first vaginal delivery, she sustained a fourth-degree perineal tear. Primary repair of this injury failed secondary to infection. Two years later, after her second vaginal delivery, she sustained another fourth-degree perineal tear, the repair of which also failed. Upon physical examination a traumatic cloaca was noted (Fig. 1). Time from second injury to presentation at our clinic was 3 years. Her past medical history was significant for multiple sclerosis, which was in remission. Surgical repair was recommended. Perineal reconstruction utilizing X-flaps, as described by Corman and Kaiser [3, 6], was the procedure of choice. The patient underwent standard bowel preparation. Broad spectrum antibiotic prophylaxis was administered. In the operating room, after administration of general anesthesia, the patient was placed in the prone-jacknife position, with the buttocks taped apart. A urinary catheter was placed. Sterile preparation and drapes were placed. The planned incisions were marked on the skin (Fig. 2). The convergence of the incisions in the center created the ‘‘X’’. Dissection of the flaps was developed to the ischiorectal fat laterally and to the puborectalis muscle cephalad. Sutures were then placed in the rectovaginal septum, both on the rectal and the vaginal side (Fig. 3). Using these sutures for traction, the septum was divided, thus mobilizing both the rectal and vaginal ‘‘tubes’’ caudally. Division of the septum was carried out up to the level of the levator muscles (Fig. 4). The next step was to identify and dissect the edges of the divided sphincter. These were mobilized to perform an overlapping sphincteroplasty. The puborectalis and levator muscles were approximated in the midline, thus reinforcing the new perineal body (Fig. 5). Overlapping of the X-flaps was then undertaken (Fig. 6). The posterior wall of the vagina and anterior wall of the anus were sutured to the newly reconstructed perineal body. Layered closure with absorbable sutures was performed. No drains were used (Fig. 7). Postoperative care consisted of bed rest for 48 h, with pressure dressings for the same time. Ambulation was permitted after this period, but sitting was discouraged to avoid shearing forces on the wound. A regular diet was started on the second postoperative day. Bowel confinement was empirically implemented with loperamide thrice daily for 4 days. Afterwards, a regimen of fibre and lactulose was initiated. Antibiotics were continued for 7 days. The patient was carefully followed once weekly for the first month after surgery. There was a minor wound disruption in one corner of the closure, which healed on its own within a month. There were no wound infections. At 3-month post-repair, there was excellent healing of all wounds. There was significant improvement in continence to flatus, solid and liquid stool. Sexual abstinence was advised for 3 months.