Anovaginal Reconstruction with Bilateral X-Flaps and Sphincteroplasty for Cloaca-Like Deformity After Obstetrical Injury

Purpose

Up to 0.3 percent of complicated vaginal deliveries may result in a cloaca-like deformity with debilitating incontinence and symptoms similar to a rectovaginal fistula because of the lack of the distal rectovaginal septum. This video illustrates the surgical technique of an anovaginal and perineal reconstruction with X-flaps and sphincteroplasty without primary fecal diversion.

Methods

The patients are placed in prone jackknife position. The flaps are marked with a pen. The junction/contact zone between rectal and vaginal mucosa is incised and the septum dissected up to the puborectalis muscle. The X-flaps are mobilized bilaterally. The posterior wall of the vagina and the anterior wall of the anal canal are then reconstructed with two suture layers each. Subsequently, an overlapping sphincteroplasty is performed and the puborectalis muscle centrally approximated. The flaps are then transposed beyond the midline to rebuild a perineal body. For all deeper reconstruction steps, 2/0 polyglactin 910 sutures (Vicryl®, Ethicon Inc., Somerville, NJ) are used; the skin is closed with running subcuticular sutures of poliglecaprone 25 (Monocryl®, Ethicon Inc.). In the end, the patient has regained a circumferentially proper length of the anal canal and the vagina, a closed ring of the anal sphincter, and a reconstructed perineal body with separation of anus and vagina.

Conclusions

Cloaca-like deformity resulting from severe obstetrical injury is the worst and most debilitating form of sphincter injuries but often is not given appropriate attention. Reconstruction of the original anatomy is more complex than a simple sphincteroplasty, but a prophylactic fecal diversion is usually not necessary. The reseparation of the rectum and the vagina in conjunction with a sphincteroplasty achieves good results.