Anorectal Malformations & Cloacal Reconstruction

Cloacal exstrophy represents the most complex colorectal malformation, requiring multidisciplinary collaboration among colorectal, urology, gynecology, orthopedic, and neurosurgical teams.[e13819-c2,e13819-c3] Prenatal imaging showing small bladder and sacral dysgenesis should raise suspicion. Initial management is not emergent; surgeons have 24–48 hours for comprehensive workup including echocardiogram, spinal ultrasound, and renal assessment.[e13819-c4,e13819-c5] NICU care focuses on preventing dehydration through plastic covering of hemibladders and NPO status. The overriding surgical principle is bowel preservation, as small intestine may be shortened and nutritional concerns are common. A novel approach leaves the fecal plate between hemibladders as auto-augmentation, connecting distal ileum to hindgut as primary anastomosis with cecum remaining attached to bladder, avoiding the traditional tubularized fecal plate that often becomes a boggy, nonfunctional segment.[e13819-c18,e13819-c17] Orthopedic closure is optimally performed within 2–3 days to leverage maternal relaxin. Dehiscence remains the most devastating complication. Comprehensive newborn reconstruction can prevent difficult reoperations in older children.[e13819-c32,e13819-c33]