V87 - Surgical Repair Of An Obstetric Cloaca

CME Eligible

Purpose/Background: A traumatic cloaca is a severe perineal injury, often secondary to obstetric trauma, that results in damage to the perineal body, separation of the anal sphincters, and loss of the rectovaginal septum integrity, leading to the formation of a single opening for both the vagina and rectum, causing complete fecal incontinence.

This video presents the case of a 42-year-old woman with symptoms of fecal incontinence. During her most recent vaginal delivery, 16 years ago, she sustained a fourth-degree perineal tear.

Upon evaluation, the patient demonstrated a Wexner score of 15 for fecal incontinence. Endoanal ultrasonography revealed a defect involving both the internal and external anal sphincters in the anterior segment. Anorectal manometry demonstrated decreased resting and squeeze pressures. The diagnosis of traumatic cloaca was established, and surgical management was proposed.

Methods/Interventions: Under general anesthesia, the patient was placed in the lithotomy position, and a urinary catheter was inserted. Standard antiseptic preparation was performed, and sterile drapes were applied. Skin flaps were outlined in an "X" configuration. The rectovaginal septum was infiltrated with a lidocaine-epinephrine solution. Flap creation was performed by sharp dissection using a scalpel and monopolar energy.

A Lone Star retractor was positioned to optimize exposure. An incision was made in the rectovaginal septum and extended along the tissue plane using curved scissors. Dissection continued with electrocautery until both ends of the external anal sphincter were identified in the anterior segment. The internal anal sphincter was subsequently dissected and its free edges isolated.

Reconstruction of the rectal wall and anal canal up to the anal verge was performed with simple interrupted 3-0 polyglactin sutures. The internal anal sphincter was then repaired using an end-to-end approximation technique employing 3-0 polyglactin suture, and the external anal sphincter was reconstructed with overlapping of its free edges using 2-0 polydioxanone suture. Subsequently, the vaginal wall was restored using 2-0 polyglactin suture. The skin flaps were then advanced into position and secured with 3-0 polyglactin. A 10-Fr Blake drain was placed in the surgical site, and the procedure was concluded without complications.

Results/Outcomes: No postoperative complications occurred, and the patient was discharged two days after surgery. During outpatient follow-up, six months after surgery, biofeedback therapy was initiated to improve continence and strengthen anal sphincter tone. Topical agents were also prescribed to promote wound healing.

At four months postoperatively, the patient demonstrated appropriate wound healing, denied dyspareunia and fecal incontinence, digital rectal examination revealed adequate sphincter tone. No abscesses or fistulous tracts were detected.

Conclusion/Discussion: In this video, we present the case of a female patient with diagnosis of traumatic cloaca secondary to fourth-degree perineal tear, surgically managed with anal sphincteroplasty and rectovaginal septum reconstruction using "X" flaps, a technique previously associated with positive outcomes. The complete surgical technique employed is described in detail in this document. No diverting colostomy was performed for this procedure. The patient's postoperative course was uneventful, and at follow-up she exhibited satisfactory anal continence and favorable aesthetic results.

Cloaca-like deformity associated to obstetric trauma
Postoperative results