Table of Contents
Cloacal exstrophy is a birth defect in which part of the abdomen is open, and some of the abdominal contents (such as the bladder and intestines) are exposed. It is the most severe birth defect within the exstrophy-epispadias complex and can occur as part of the OEIS complex, which is characterized by omphalocele, exstrophy, imperforate anus, and spinal defects. It is a rare congenital malformation, occurring in 1/200,000-400,000 births, and is diagnosed by prenatal ultrasound. In cloacal exstrophy, there are two exstrophied hemibladders separated by a foreshortened cecum or hindgut, often characterized by a blind end, resulting in an imperforate anus. There is significant diastasis of the pubic symphysis, and the phallus is separated into two halves along with the scrotum. In males, the penis is usually flat and short, with the exposed inner surface of the urethra on top, and split into a right and left half. In females, the clitoris is split and there may be two vaginal openings. This condition is also highly associated with other birth defects, especially spina bifida, which coexists in up to 75% of cases. Multidisciplinary care followed by surgical management should begin immediately following the birth of the patient. Closure of the meningocele and omphalocele, as well as adaptation of the bladder halves, should be started in the neonatal period, followed by a multi-stage approach for bladder, bowel, and genital reconstruction (including a pelvic osteotomy) at a later time. Here, we present a patient who was diagnosed with cloacal exstrophy by prenatal ultrasound. The urinary bladder and intestines were noted to be outside of the body and associated with a closed myelomeningocele. The exstrophied cloaca was repaired and reduced back into the abdominal cavity. Urinary and fecal diversions were created, and a leg casting was placed for pelvic osteotomy.
abdominal wall; abnormalities; omphalocele; bladder; urogenital
Cloacal exstrophy occurs in about 1/200,000–400,000 live births.1 The term cloaca refers to the pelvic malformation in which there is the confluence of urinary, genital, and gastrointestinal tracts.2 Cloacal exstrophy is the most severe variant of a spectrum of disorders that develops from the inappropriate bridging of the cloacal membrane and urogenital septum. These disorders have been termed the exstrophy-epispadias complex (EEC). In addition to cloacal exstrophy, the other two disorders of the EEC are bladder exstrophy and epispadias, listed in order of decreasing severity. In addition, cloacal exstrophy can occur as part of the omphalocele, exstrophic cloaca, imperforate anus, and spinal defect (OEIS) complex, which is present in this case.3
In cloacal exstrophy, the cecal plate and hemibladders are inappropriately attached to the skin and muscle of the abdominal wall. The repair involves detaching the cecal plate from the abdominal wall, and then reducing the intestine and hemibladders into the abdomen. The intestine leads to a blind end with an imperforate anus, which is resolved by suturing the intestine into an ostomy to divert feces to the skin surface.
Cloacal exstrophy was identified during a prenatal ultrasound. This infant had all four major criteria used for identifying cloacal exstrophy. The major criteria are nonvisualization of the bladder, a large midline infraumbilical anterior wall defect or cystic anterior wall structure (persistent cloacal membrane), omphalocele, and lumbosacral anomalies. Minor criteria that are more scarcely present include lower extremity defects (club feet present in this infant), renal anomalies, ascites, widened pubic arches, a narrow thorax, hydrocephalus, and one umbilical artery.4 When prenatal ultrasound is nondiagnostic, fetal MRI may clarify the diagnosis of cloacal exstrophy and aid in prenatal planning.5
The patient is a male neonate presenting with the OEIS complex. He has a prolapsed terminal ileum through an omphalocele, which has the appearance of an “elephant trunk.” Umbilicus is absent. Genitalia consists of a split hemiscrotum and a rudimentary phallus covered by a urethral plate. The anus is imperforate, and the feet are clubbed bilaterally.
Plain films, CT, or MRI of the patient, to be uploaded separately from the text.
Cloacal exstrophy results from the failure of migration of the lateral mesodermal folds. It has variable presentations depending on the stage of the infant’s development that the failure occurs in. The failure of migration prevents normal mesodermal ingrowth to the cloacal membrane. This results in an ill-supported membrane causing premature rupture, which results in varying severities of abdominal wall defect. This migration failure most likely occurs within the first 8 weeks of gestation.6
Standard treatment for cloacal exstrophy is an urgent surgical repair of the omphalocele within the first days after birth. Early intervention prevents the inevitable onset of sepsis and nutritional deficits that would be life-threatening to an infant who went without surgical intervention. In recent years, the treatment of cloacal exstrophy has improved to become a consideration of the quality of life rather than a question of saving a life.7
Historically, the two most common surgical approaches have been a one-staged approach and a multi-staged approach. Recently, Jayman et al. demonstrated the odds of having a successful closure are 3.7 times greater for the multi-staged approach compared with the one-staged approach.8
The initial goal of surgical intervention is to create safe bowel and bladder outlets to prevent infection and preserve tissue. An early concern in infants is the onset of sepsis, and a more farsighted concern is to save as much bladder and intestine as possible while closing the omphalocele to maximize bladder growth and intestinal absorption potential for when an ileostomy or colostomy is placed at a later time. Colon preservation is of the utmost importance for maximizing the infant’s potential for electrolyte absorption and stool continence.9
In a multi-staged surgical repair, the first stage of surgical intervention is performed neonatally and consists of an omphalocele repair, separation of the hindgut, approximation of bladder plate, and canalization of cecum into an ostomy.10
After the cecum and bladder are detached from the abdominal wall, the cecum is canalized via suturing to form a tube that drains into an ostomy on the surface of the skin. The bladder tissue is also mobilized and sutured off to form a functional bladder, which will have a catheter draining to the skin’s surface. Intervention at a later time will address methods to gain urinary continence.
Prior to the development of surgical techniques to repair the abdominal malformations of OEIS syndrome, cloacal exstrophy was a fatal condition.11 Current survival rates range from 98–100%.2,12 Jayman et al. have shown a 100% success rate through 34 cases of closing the cloacal exstrophy successfully on the first attempt by using a dual-staged pathway.10 The multi-staged pathway has exhibited improved success rates by delaying the closure of the bladder, which allows the infant to develop better nutritional status and to grow more bladder tissue before relocating the bladder deep into the pelvis.10
Recent studies have demonstrated technique modifications that improve outcomes and are the current standard of care. In this case, a pubic symphysis stitch was used to decrease the tension put on the abdominal wall sutures following the repair of the omphalocele. The complication rates of the first surgical stage can be decreased from 89 to 17% by decreasing the diastasis of the anterior pubic rami to prevent dehiscence.13
Additional techniques include postoperative immobilization with external fixation using modified Buck’s traction for 6–8 weeks, when an osteotomy will be performed to approximate the pubic rami. If an osteotomy will not be performed, postoperative immobilization with modified Bryant’s traction for 4–6 weeks was most effective.14 In patients having an osteotomy performed, pediatric orthopedic surgeons were shown to have success rates significantly higher than general orthopedic surgeons.15
The second stage includes closure and placement of the bladder deep into the pelvis, followed by an abdominal wall closure. 2–3 weeks prior to abdominal wall closure and deep placement of the bladder, the first stage of osteotomy is often performed to prevent dehiscence once deep bladder placement occurs. Infants with a diastasis measurement greater than 4 cm undergo a staged osteotomy, rather than an osteotomy performed on the same day as the bladder closure.10
A significant factor for gaining urinary continence is the success of the initial surgical formation of the bladder.17 In 2018, Maruf et al. demonstrated that urinary continence could be gained in 71% of patients with cloacal exstrophy who underwent additional procedures to gain continence.18 The median number of additional procedures for urinary continence following the initial bladder closing procedure was 2 (range 1–4), and the median age of attainment was 11 years.18 A 1989 series by Mitchell et al. demonstrated that all 10 patients who underwent bladder reconstruction to gain continence were able to stay dry for periods of 3 or more hours through the use of a continent stoma and clean intermittent catheterization, and 50% were totally dry during both day and night.19 Clean intermittent catheterization was required of all patients in the study except one.19
In addition to bladder continence, intestinal continence can be gained. Although it was once thought that all patients with an exstrophic cloaca would require a permanent stoma for passing bowels, a 2008 study of 20 patients born with cloacal exstrophy and treated with a colonic pull-through indicated that 17 (85%) of the patients were clean with bowel management at the time of follow up.16 Another benefit of the colonic pull-through is the maximization of colonic tissue for increased nutrient absorption and the formation of solid stool.
Historically, different factors have contributed to assigning gender to 46XY infants with cloacal exstrophy and ambiguous genitalia. In a 2011 study of gender assignment for newborns with 46XY cloacal exstrophy completed by fellows in the Urology Section of the American Academy of Pediatrics, 79% of fellows favored male gender assignment, with the most important factor in male assignment being androgen brain imprinting.20 Of the fellows who selected female assignment as most appropriate, the factors cited as important in their decision making were the high likelihood of functional female genitalia and the uncertain results of male phalloplasty.20 The perspectives regarding gender assignment have morphed over time. In a review of patients from 1974 to 1992, 12 of 13 genetic males treated for cloacal exstrophy were given the female gender.2 Whether a patient’s gender is reassigned or not, it has been recommended that all patients with cloacal exstrophy undergo long-term psychological counseling to cope with issues such as dating, sexuality, marriage, and depression.21
5-0 Vicryl chromic,
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Woo LL, Thomas JC, Brock JW. Cloacal exstrophy: A comprehensive review of an uncommon problem. Journal of Pediatric Urology. 2010;6(2):102-111. doi:10.1016/j.jpurol.2009.09.011
- Lund DP, Hendren WH. Cloacal exstrophy: Experience with 20 cases. Journal of Pediatric Surgery. 1993;28(10):1360-1369. doi:10.1016/S0022-3468(05)80328-8
- Zhu X, Klijn AJ, de Kort LMO. Urological, Sexual, and Quality of Life Evaluation of Adult Patients With Exstrophy-Epispadias Complex: Long-term Results From a Dutch Cohort. Urology. 2020;136:272-277. doi:10.1016/j.urology.2019.10.011
- Austin PF, Homsy YL, Gearhart JP, et al. THE PRENATAL DIAGNOSIS OF CLOACAL EXSTROPHY. The Journal of Urology. 1998;160(3, Part 2):1179-1181. doi:10.1016/S0022-5347(01)62733-2
- Chou C-Y, Tseng Y-C, Lai T-H. Prenatal Diagnosis of Cloacal Exstrophy: A Case Report and Differential Diagnosis with a Simple Omphalocele. Journal of Medical Ultrasound. 2015;23(1):52-55. doi:10.1016/j.jmu.2014.11.002
- Phillips TM. Spectrum of cloacal exstrophy. Seminars in Pediatric Surgery. 2011;20(2):113-118. doi:10.1053/j.sempedsurg.2010.12.007
- Shah BB, Di Carlo H, Goldstein SD, et al. Initial bladder closure of the cloacal exstrophy complex: Outcome related risk factors and keys to success. Journal of Pediatric Surgery. 2014;49(6):1036-1040. doi:10.1016/j.jpedsurg.2014.01.047
- Jayman J, Tourchi A, Feng Z, et al. Predictors of a successful primary bladder closure in cloacal exstrophy: A multivariable analysis. Journal of Pediatric Surgery. 2019;54(3):491-494. doi:10.1016/j.jpedsurg.2018.06.030
- Soffer SZ, Rosen NG, Hong AR, Alexianu M, Peña A. Cloacal exstrophy: a unified management plan. J Pediatr Surg. 2000;35(6):932-937. doi:10.1053/jpsu.2000.6928
- Jayman J, Michaud J, Maruf M, et al. The dual-staged pathway for closure in cloacal exstrophy: Successful evolution in collaborative surgical practice. J Pediatr Surg. 2019;54(9):1761-1765. doi:10.1016/j.jpedsurg.2019.01.005
- Flanigan RC, Casale AJ, McRoberts JW. Cloacal exstrophy. Urology. 1984;23(3):227-233. PMID: 6702034.
- Smith EA, Woodard JR, Broecker BH, Gosalbez R, Ricketts RR. Current urologic management of cloacal exstrophy: Experience with 11 patients. Journal of Pediatric Surgery. 1997;32(2):256-262. doi:10.1016/S0022-3468(97)90190-1
- Ben-Chaim Jacob, Peppas Dennis S., Sponseller Paul D., Jeffs Robert D., Gearhart John P.*. Applications of Osteotomy in the Cloacal Exstrophy Patient. Journal of Urology. 1995;154(2):865-867. doi:10.1016/S0022-5347(01)67187-8
- Meldrum KK, Baird AD, Gearhart JP. Pelvic and extremity immobilization after bladder exstrophy closure: complications and impact on success. Urology. 2003;62(6):1109-1113. doi:10.1016/S0090-4295(03)00791-X
- Sirisreetreerux P, Lue KM, Ingviya T, et al. Failed Primary Bladder Exstrophy Closure with Osteotomy: Multivariable Analysis of a 25-Year Experience. The Journal of Urology. 2017;197(4):1138-1143. doi:10.1016/j.juro.2016.09.114
- Oesterling Joseph E., Jeffs Robert D. The Importance of a Successful Initial Bladder Closure in the Surgical Management of Classical Bladder Exstrophy: Analysis of 144 Patients Treated at the Johns Hopkins Hospital Between 1975 and 1985. Journal of Urology. 1987;137(2):258-262. doi:10.1016/S0022-5347(17)43972-3
- Maruf M, Kasprenski M, Jayman J, et al. Achieving urinary continence in cloacal exstrophy: The surgical cost. Journal of pediatric surgery. Published online January 1, 2018. doi:10.1016/j.jpedsurg.2018.02.055
- Mitchell ME, Brito CG, Rink RC. Cloacal Exstrophy Reconstruction for Urinary Continence. The Journal of Urology. 1990;144(2, Part 2):554-558. doi:10.1016/S0022-5347(17)39521-6
- Cohen AR. The mermaid malformation: cloacal exstrophy and occult spinal dysraphism. Neurosurgery. 1991;28(6):834-843. PMID: 2067605.
- Diamond DA, Burns JP, Huang L, Rosoklija I, Retik AB. Gender assignment for newborns with 46XY cloacal exstrophy: a 6-year follow-up survey of pediatric urologists. J Urol. 2011;186(4 Suppl):1642-1648. doi:10.1016/j.juro.2011.03.101
- Mukherjee B, McCauley E, Hanford RB, Aalsma M, Anderson AM. Psychopathology, Psychosocial, Gender and Cognitive Outcomes in Patients With Cloacal Exstrophy. The Journal of Urology. 2007;178(2):630-635. doi:10.1016/j.juro.2007.03.144
Table of Contents
- Draping and Planning
- Mobilize Omphalocele and Ligate Umbilical Vessels
- Establish Plane between Cecal Plate and Rectus Sheath
- Identification of Bladder and Testicles
- Identification of Hindgut and Future Stoma
- Closure of Cecal Plate
- Reduce Bowel
- Dissection to Identify Corpora
- Division of Urogenital Diaphragm
- Placement of Ureteral Catheters
- Creation of Neo-urethra and Reassessment
- Ostomy creation (not shown in this video)
- Mobilization of Corporal Bodies
- Place and Suture Malecot Suprapubic Catheter
- Closure of Bladder
- Placement of Pubic Symphyseal Stitch
My name is Carl Christian Jackson. I'm a pediatric surgeon at Floating Hospital for Children Tufts Medical Center, and we’re going to be taking care of a baby today with cloacal exstrophy. The twin had no congenital abnormalities, but on prenatal ultrasounds, cloacal exstrophy with associated myelomeningocele was identified in this baby. And today we're taking a multidisciplinary approach to addressing the cloacal exstrophy.
Our first goal with the surgery is to free up the intestine from the belly wall. With the exstrophy, the abdominal wall did not close normally, so the intestines and bladder are exposed and are attached to the - the rim of muscle and skin. So we want to separate those so that we can then identify what is intestine and what is bladder. So our first goal after freeing up what's called the cecal plate peripherally is then to separate the cecum and the cecal plate from the bladder plate and then put those together with stitches to make it into a nice tube again because right now it’s - it's splayed open. So we want to get that back into a tube and then eventually form that into an ostomy. So that will come out somewhere on the belly so when the baby stools, it will come out here as opposed to the bottom.
And that will be the first part and as - as a component of that will be Dr. Wiygul intimately involved with us in freeing up the bladder, identifying the ureters to make sure that those are protected and not injured, and that'll be sort of the initial phase. The next step will be assessing whether or not to do the pelvic osteotomy where the pelvis is - is broken in a controlled fashion to then try to rotate it. Right now, the pelvis should be - or the pelvis should be a ring. Right now, it's wide open, and then the osteotomies can help free things up so you can bring the pelvis back together to create a normal ring.
So it - it’s - the overall goal sounds fairly straightforward and short, but the very time-consuming and delicate part of this is to identify all the structures so that nothing is damaged and that we can get the anatomy back to an - a functional result. And there will be staged operations, probably further operations, in the next several months and years to - to try to get the baby back to as - as optimal a state as possible.
In classic cloacal exstrophy, you have an omphalocele, which is this area here, this yellowish area here, and then you have what is - what is prolapsed terminal ileum coming this way - that's what's - what's on prenatal ultrasound identified as the elephant trunk, and then you have the cecal plate here. And you'll notice that the patient does not have a bell - does not have an umbilicus. In cl - in bladder exstrophy where there’s not involved - the GI system is not involved, you have an umbilicus, but it is actually low set. And that's actually removed during the course of the surgery, and a new umbilicus is created. What we bel - what we believe we're seeing is actually the hindgut that will be in continuity with the cecal plate here and will be mobilized during the course of the surgery. And then with the related GU defects, you have split hemiscrotum and then potentially a rudimentary phallus here that is covered by what appears to be urethral plate.
As part of the OEIS syndrome, which is the omphalocele exstrophy imperforate anus and skeletal defects syndrome, which is what this child has, the associated skeletal defects tend to be clubbed feet, and as you can see, there’s no anus. And in addition, coming off the side here is a very large covered myelomeningocele. That means the actual neural components are not exposed to air and they’re - it's covered by skin. If this was not covered by skin, this would actually be the first defect that was closed for this child. And then also because these children tend to have very largely, widely spaced pubic rami, that's the ring of the pelvis, you can actually feel them here where my two thumbs are, and what we will do is create pelvic osteotomies to allow sort of inward hinging of the - of the pelvis so that we can close the - the pelvic ring. It's actually very important - that is a crucial step in this operation, because if you do not close a pelvic ring without tension, that increases the chances of dehiscence of the wound and extrusion of the bladder.
Bilateral ureteral catheterization, closure of cloacal exstrophy defect, and omphalocele - and an osteotomy. It kind of reduces really nicely. It does - it does. I mean, I kind of want to drape him like - like from the knees down if we can and just sort of cover things - try to minimize the bacteria. Okay. So this is our cecum. I think the cecum’s up to here. Yeah, I think bladder probably comes there. Yep. And then, our two presumed ureteral orifices - oh actually, I think this - I think - I think - I think we might be swinging up - up this far too, you see that? Yep. Yep. All that looks like bladder plate to me. And how about inferiorly? That’s hindgut, I think, and then right above here is bladder neck right there. You see what I’m saying? So - but I think once we start the dissection, it’ll release a little bit more. Yeah, once you do a circumferential dissection and probably start laterally where we know we’re safe, come around - I think, go in through the omphalocele. Right, yeah, yeah. And then coming down laterally. And then we can see - see what we got.
So now we’re going to mark out his umbilicus. You go off of the anterior superior iliac spine. So I’ve got the bowel underneath. There we go - tells us we’re in. You want to put a Ray-Tec in there or are you comfortable as is? It’s fine. Whatever you want to do. If you didn’t want to do the - that, I’ll run Bovie. That tells us we’re in intra-abdominal - that's for sure. Think I'm going to run right under. Now we're just freeing up the junction between the omphalocele and the bowel with the native healthy skin, and we can follow that ridge and that normal intestine popping out at us that we do not want to injure.
Now this is clearly one of the differences between cloacal and bladder exstrophy; we spend all our time trying to stay out of the peritoneum in the bladder exstrophy cases. It’s sort of impossible here, obviously. But these are the umbilical vessels, correct? Yes. That we’re seeing? So presumably, this is going to be the umbilical vein. There you can - there you can see nicely the lumen of the vein. In an adult you could leave these bleeders alone and not worry about them as much, but in a 6-day-old infant, we take all bleeding seriously. So I wouldn’t go - see where my finger is? Don’t go any further, yeah. I can see right here. Oh, okay. We’re starting to see the backside. Okay. So there - actually, there’s - there’s liver and gallbladder.
So there’s appendix right there, and you can see that it’s attached to these two orifici that we were thinking were per - perhaps the ureteral orifices. And then if you look here based on the vasculature, I think this is bowel wall. I think this is peritoneum, so I think that is our demarcation line. So I think - right along the line of the omphalocele. We’re getting into tiger country over here, I think. So I think that - I’m not sure what that is, but I’d like to avoid it. Sure, let me take a feel in here real quick. Running up this way are his vessels. This thing here kind of feels like a testicle, or it could be his - it could be his - we can get this out, right? Yeah, whatever this is, I’ve got it on my finger, so you’re far away there. Sure. We think this is... right… Do you want to just clamp and tie this? Sure. There is a potential there was a vessel here. Do you have a 3-0?
Specimen. That actually could be a - that could be a hernia we’re feeling, actually - now that I think about it. What are you calling this? We’re calling that - umbilical stump - right umbilical stump. Okay, so we’ve mobilized that there. Yeah, I think you’re - I think the bladder is way down here. Yeah. Actually, that - here we can try to get that - right on the other side. So actually, because this - yes. I’ll take this off on this side. Actually, what I was saying before you - cut it there first. Can I see that? Yeah. You can probably cut through this. Yeah, I think - I think you’re clear there. And here we just need to be cautious - see where our - that vessel runs. Vessel’s down there. Something’s down there. So I think here’s - that’s all free. So if we cheat here, I wouldn’t - is there anything there that we have to worry about? That feels like a vessel there. So I think we should be able to come - no, I think that’s your - your cut vessel. Yeah - no, but I think that’s - you know, what’s - that's - going where? Because if this - if this is our umbilical - if this becomes our umbilical vein, then that’s fine. We just come all the way across that.
I’ll take it - I got it. Old clot. Thank you again. Can you see on that side? There we go. So I’m coming - I would agree with that. Now just peeling away - that’s a good sign. Just walk towards the top - towards the top. Sure. You want to come on the other side then? Yeah, okay. You want to flip it this way now? So, alright now we’re starting to see something here, okay. Yeah, there’s - there we are. Now you can see - now this is starting to look - yeah, this is probably good. So - left side - like with my orifice, I’m looking at the - so that’s cecal plate right there. Right. Right? And where the hell is bladder? So here’s - DeBakey, please - so here’s appendix. That looks like one, and I think we had a second one, didn’t we? Yeah, the second one is on the other side. Yep. So we have two, which is very common. Is this the bladder? No, I don’t think so. I think we need to release here a little bit. It’s coming - it’s coming from below. What I think is happening is we’ve got a bladder plate sort of just sitting down like this, and then the cecal plate kind of starts off behind it like that. That seems like that’s bladder down there. He’s obviously making some sort of urine, so.
So what I think - what I would like to do is mobilize this a little bit more and just see if we can get things to pop up, and then just by virtue of pulling up, maybe we can see a little bit more. Right angle? Right here. Yeah, that looks good. I don’t have great dissection there. Yeah, hold this. There’s not really a good plane. I don’t know if you can see better. No, I’m just trying to think about what - what we would be running into here. Coming up and outside - yeah, I’ll take it like this, and that looks like testicle right there. That looks like a testicle - that is a testicle. Well, you don’t - but because then you don't know what's - well, I don't want to d - I don't want to be down here because there’s literally - there could be - urethra - yeah, there’s all sorts of things down there. So if that’s testicle, can we come... I think I just buzz it. What - you were saying with testicle, that we can come lateral? Can we - can we - I mean, we can get in here. Is that - is that going to give you trouble or is it better just to kind of leave it - well, I’m just wondering what exactly we’re doing with it. Like, how are we - just, is that going to give us any exposure if we can take that laterally and - and take this down? Does that help us or no? No, I don’t think so. This is attaching into here. The problem is - is that we need to - we really need to have this up so I can see what’s below it. That’s the issue.
So this - we see the hindgut and trying to free the hindgut from - from - you know, from the inside? That’s - so that’s all in continuity, right? So that’s got to all be gut, right? So we said cecal plate central and bladder plate lateral? Lateral. And does he not - just not have a - does he not have a bladder plate then? I guess that’s a possibility. We’re just looking - but we know he’s making urine, right? Right, like otherwise - yeah, otherwise - his ureters have got to be going somewhere because he’s got normal looking kidneys, so he’s got to have ureters entering into someplace - and it looks like they’re coming down here. Let’s see. So, this to me, what I’m seeing here, is sort of the - like sort of the limit to the cecal plate here. You agreeing with that? There’s certainly a transition there. Yeah. I’m wondering if we can get into that plane and sort of - just sort of get into the peritoneum - underneath the peritoneum, and see if we can bring that down. I mean, everything inside of this has to be cecum, correct? Unless we - is there - can we have an - an ectopic bladder inside of a cecum?
Where’s the ureters? So like, I think this, right? And then can I have a pickup? That’s cecum. That’s cecum. That’s bowel. That’s bowel. But where does this bowel go? Like, that’s - that’s hindgut. That’s hindgut? That’s hindgut because that’s foregut. Let’s see. You got foregut - yeah, pull - this is hindgut. This is my finger going down the hindgut. Let’s free that up. Yeah. And do this? Yep. Okay. Does that help with my finger in there, or? I’m not sure. Okay. So if that’s mesentery - yeah, because that looks like - so let's try there. So why don't you try to get into this space right here? Because that’s - yep, and that’s appendix there, so I think we can probably come into this. Bovie.
And so actually, let’s trace mesentery here. You got that? That’s mesentery. That’s mesentery. How about from that side? Because can we - because this is - is that mesentery or just some - some stuff? That’s some stuff. Just some stuff. Yep, there we see some mesentery, I think. Okay - yep. So I think this can probably come down. That looks like - yeah, I think once we get this fully mobilized, it’s going to give me a better idea here. We basically just splay out the bowel so it’s - we can - we know what’s what. Looks a little thick there.
There’s - that’s mesentery there, I think. Mesentery. So that’s mesentery coming this way - down - which means that this should be anti-mesenteric if we wanted to take it. Run along this way? But we don’t what that is. But we don’t know what’s what yet. Let’s - I think what - there’s a plane we can get into above this. But I think if - if this is showing this a little better, this is - this looks like cecum and that may be division there. Bladder? Could be bladder here. We have cecal plate centrally, ureter coming - you know, the - the bladder plate laterally. Because we could - potentially, this - we cut this. If the cecum comes here and the hindgut goes there - and then this is cecum, and then the rest, whatever down there, is bladder. Yeah, that - you’re - you’re right. You’re probably right. So part of this is bladder probably, like - see - well that - I thinking - I’m thinking because you can see the cecum very dilated, and then there’s a transition. And as - you know, could that be why we had some - sure - although we didn’t really cut in there, but you know, could this be bleeding because we’re coming across? This actually could be ureter coming in through here. Yeah, and that’s where - when do you want to - do you want to canalize? Well, I can’t find the UO yet.
That certainly looks like a UO but… Grab close to me. I got it. I’m - I’m supporting it. Nah, I think it’s just curling up. It looks like it’s in there. Or is it just because it’s on the back side of it? Let’s try this again. Now I’m starting to see this - I think this is bladder right here, you see this? So bladder, bowel? And this is - yep, yep. I think that’s what we’re seeing now. We can see that a little bit more clearly. That trabeculated stuff - that’s going to be - that’s going to come down? Yep, yep. So I think this is it. Yeah, I can see that a little bit more clearly now. And what is - is that just - that’s going to be a part of your bladder right across there? I think that - yeah, because this is trabec - these are - these look like striated fibers that come with the - or the sort of crisscrossing fibers that come with the bladder. Right.
If we had to, we could cheat a little bit here tow - to leave you - so we know we’re not - taking on your bladder more than you need to. But let’s confirm where the hindgut is, obviously, before we do that. So I think that’s that. So hindgut is here. Yeah, so it’s above where I’m holding, I think. Yeah, so this - hold on a second. Yeah, this is all bladder down here. I’m almost positive of it now. This stuff - okay. All this is here, and then the hindgut is up this way. Yep, and you see that? Yep, that is - this is - this bladder mucosa looks very thin and attenuated, so we just got to be aware of it.
Here is - this is hindgut going this way, so I’m thinking like a - like across like this. Let’s make sure we’re clear on the backside there. Make sure the testicle is down. Yep. So I’m going to come across here? Yeah, that looks good, yep. Not much of a bladder - not much of a bladder. So that’s bladder right there, see that? Okay. Now it’s starting to look like something real. You’re coming in. Hold on - you’re coming in. Can I get through? No, you’re getting into gut here I think. Maybe you go - maybe you go a little more superficial? What I’m think - yeah, why don’t you go superficial here and we go by layer, what do you think? Yeah. DeBakey, please. So I’m going to come across here? Yep, I agree with that.
Okay, just to show everyone: hindgut coming this way, cecal plate here, presumptive bladder right here, and we’re separating the two. I think that's - can you see it there? I can see that.That's just - we kind of buttoned the hole a little bit. I think this can come down.
Here’s our - our ileum. Let’s get our - coming to cecal plate, we’ve got one appendix there. We have our other appendix - the upper - right - ah, here. So that seems relatively free, I think. I mean, this is testicle here. And you just sort of do this movement. Actually, if we want, we can just sort of tuck it away. Is that the end here? I think you’re right because there’s - there’s mesentery - yeah. There’s gut. Yeah. I don’t think - I don’t know - I don’t think we need to - I don’t think we need to take it, is our blind end. And that’s what you’ll bring up? That’s what we’ll bring up.
Alright, let’s take another look at this. So actually, there is our gut, small bowel - we need tubing - cecal plate, our two appendiceal tips - and heading down into hindgut - heading into hindgut that way. Actually, we could probably take that mucosal ridge there. If we start here - this is anti-mesenteric here. That’s lined up. If we run that up - and this - a little of this also we could freshen up. That is your - your omphalocele. That’s true. We can just cut across a little bit here. Yeah. That should be my fingers right there. Yeah. This is the end of the bowel right here, and this will be the part that becomes the stoma.
This is cecum. This is large bowel. Now we have to try to set it up in here. And did you want to address that? So now we’re closing the cecum, the - that part of the bowel that we saw at the beginning of the case that looked like an elephant trunk is actually this part right here that has now been everted back into its normal position, and we’re closing the plate. I’m hoping to imbricate that little bit. DeBakey - actually, a Gerald if you got it. You want me to imbricate where? This part? Yeah. I was always taught interrupted. One of the guys I worked with trained in Argentina. They did everything running. Probably doesn’t make a bit of difference as long as you have good technique for your apposition - of your chosen, right.
So all, I’m just saying that we’re almost - almost done with closing the cecal plate, and Jeremy is up for the bladder component. And then I will probably do the ostomy at the end. Is that how you want to do it? Yeah, sounds good because you don’t know what - because once you make the ostomy, you don’t want to be tethered and all that stuff - and then the exposure - it can move - yeah, move the bowel out of the way. Yeah. Well, should we keep the skin on antibiotics? Yeah, prob - probably at least 48 hours. 48 hours. Even with more tiny kind of cuts? Happy with your side. Scissors please. Below. Below. There you go.
Cecal plate is now closed. Show that. Have a little tiny - yeah, that’s it. Cecal plate there. Wonderful, thank you. Okay. Can I do this for you guys? Yeah, and actually, you can probably - what’s even better would be to tuck some of that back in. Okay. Pushing it up. Come on - can you… You have the peanut? Ta-da. So I want - if you want to see, here’s - here’s our de - our fascial defect at the end. It’s a small omphalocele. That’s relatively small.
Floor. So I think that’s - yeah, that’s all corporal tissue right there. Take a Bovie and - and just buzz right between my... Starting here, and then where do you want to end up? I would just come down to here and then we’re just going to - we’re going to dissect from there. Okay. There’s a lot of stuff not making sense about this, and now I’m starting to understand it a bit better. Adson with two - do you have an Adson for Dr. Wiygul? Oh yeah - you can buzz through the skin there. You’re safe. Yep. Good. And that is? Those look like corpora. There you go. Adson with - yep, yep, yep. So where do you see corpora? Right here. Ah, there’s one. That looks like corpora right there. Okay, buzz in the middle here a little more. Release that. Coming right there? Yep, yep, yep. As long as you’re in the midline, you’re safe. Okay, stop. Let’s see here. That - that right here.
That is just a blind ending - bladder - bladder. So that should be - would you then - what I want to do is detach this and bring it up. Detach all this and bring it up so the bl - so it’s - so it’s draining onto the - draining onto the - onto this. And what I could do is, is I could detach it from wherever it’s - wherever it’s tethered here and then bring the - and anastomose it to the skin here. And that way you’ve at least got a - a urethral opening draining - draining low and then you bring the - and then you bring the - the pelvic bones over the top. So let’s say it’s coming down like this to a point, right? The bladder is blind ending right here. You detach it, you bring it up, and then you sew the back end back to the skin, but we need to - we need to identify the corpora a little bit more so we know what our lateral extents are. The problem is is we don’t have any actual urethra. Yeah, I think you’re bringing up midline too. Midline - no, I’m - I’m meaning to, yep.
Retract there a little bit for me. Did you want that? Can you retract - yeah, there you go. Perfect. Careful here. Where’s the bone? DeBakey. So we’re right on bone right there. That’s - I’m right on top of the pubic bone if you can feel right there. Over here? Yeah, so we’re dissecting some of this off, so we got to be careful. So this is - that’s corpora right there - and then - the left corpora - you see, yeah, it’s coming this way. Yeah. And traditionally, this is where the anter - intrasentential bands are, but you can define a little bit better because you can see where the bladder neck is. And you can go lateral to that, and you actually retract the - the pubic bone. Got to find that pubic bone, which is right here actually. Right here.
Okay, so here’s bladder. Actually getting around the backside there, aren’t we? Let’s think about this. Does this make sense to do this? Here’s corpora. You can clearly see that. Tenotomies? Everything is fine. Adson - the teeth. So the reason why I’m - I’m even messing with the corpora is that they - if I can follow it down, then I know where I am in terms of the - of this dissection. Okay. And I’m not - you know, not just sort of blindly cutting. See, all of this needs to go, this stuff here. Yep. And you can actually - that looks like corpora right here, coming down like this. It’s coming from behind. Starting down that way. Yep. Come across here. Done. Come there, come in. It’s actually becoming much clearer now, you see that? Yeah. And I think if we stay on this side... DeBakey’s.
I know this seems sort of gratuitous, but this is actually really going to be able to let me define the anatomy a lot more - and especially since this is not run-of-the-mill stuff. Let’s go. Let’s feel where the pubic bone is. Yeah, we got to take these down. Pass over here - I think we’re over. Yeah. Yeah. Over here. Actually by doing this, I can potentially give him a little bit more penile length too - so connect in here. What I’m trying to understand is what this tissue is. So this is bladder neck. This all looks like what - what would have been bladder neck. And then the phallus - and then the suspensory ligament is there? Yeah, this is suspensory ligament here. Very good. And then - and then we have this tethering here. Just want to make sure I’m not - can I have the Bovie? Good. Alright, that’s perfect. And the other?
Yeah, so we’re coming right up on the pubic bone on that side too. And you see how this dissection lets me see where the corpora is and - yeah - makes sure I’m not doing anything terribly stupid. Another Babcock, please. Got one here. Got it. I just want to be gentle with as much of the bladder as possible so we’re not renting things. Okay, and come in here again. That is where we need to be, right there. So let’s get a hook. You feel the bone? It’s right here. Right here, right here. Right there. And get on that and retract. Perfect. Bone there. Yep. This is bone right here. Okay. I just wanted to know if it was periosteum - that’s why it was bleeding into the thing. Yep. You’ve got to be careful, because if you go any further that way, you’re into corpora, and that’s a very hard thing to get to stop to bleed. Let’s see here.
It’s a little more easy with this part - just so you guys know. I feel like we should be there. This is - this is pubic bone right here. I think that… Take a feel - just, you can feel that - you can feel that there’s a band sort of still there. You see what I’m saying? So that’s the problem. Here’s the pubic bone right there. I think we can do a little bit more right there. And then, is it - am I going to be able to drop that in? Can you hold it like that - just gently, obviously? Yeah.
So it’s clear on this side I feel like, but this right here is the problem. That’s where you had to suture? Yep, yep. So I think I need to be here. Can you hold that? You’re just kind of riding the pubic? Exactly, right on top of it right there. So yeah, I think that we can definitely get over - like that’s far enough there. Let’s look over here again. And the question is is are we far enough over here. I think so. I don’t know - it’s totally different. It’s completely different. The bladder is not free from the side walls. Yeah, so this is right - here’s the pubic bone right there. That’s periosteum I’m on right now. That’s a vessel right there. Put your pickups on that again, I’m Boviting it. Okay - letting go. Go ahead. Just above it. Alright, so I think that was a good blow there. Yeah, I feel like we’re pretty close. Now, we may need to take that down a little bit more. Corpora is running here - yep, yep, and I think we can come here. That’s just fat right there.
Okay, so this is bladder neck here. So there’s the pelvic floor there. Come this way a little bit. Now, the issue is - just look how thick this actual bladder neck is, and we’ve got to be able to drop this down and bring this over the top of it. I think we can do that - there and there. And then so where is the urethra going to come out? Right, so he’s got no urethra. Yeah. Whatever urethra we create for him will have to be a neourethra so from skin or something like that - or bubble - bubble encase it. Is that something we’re going to do now? No, no, no. So what we’ll need to do is I’ll close the bladder, we’ll put a - a separate SP in, then I’ll put the - the pubic stitch in, bring the - bring the symphysis together, and then you guys can close. Okay.
This would make things a lot nicer for him. So, where is urethra? Should - urethra should be deep to the corpora right? Yeah, but in these cases they’re usually shallow. There’s usually an epispadias, but I’m starting to feel like all bets are off in this kid. Sometimes, it’s better to be lucky than good. Okay. That’s one in. Okay, can I get a 5-0 Vicryl - chromic, please. Now the issue here is is that normally I would drain these to separate bags, but because I’m going to have to bring it down through this neourethra, I’m going to have to cut these off more than likely. Do you want to mark it in some way, right and left? Yeah. Yeah, we’ll definitely do that, but I’m just thinking in terms of being able to drain things.
So UO should be over here somewhere. Can you get the - there you go. Good. Yep. So let’s see where the other one is. Okay, now I’ll take the - catheter? Yep. It’d be a very strange place to have another UO. It’s going nowhere. Going towards you, or? Normally - I mean, you can try - I don’t think it’s going to make a huge amount of difference. Will it allow you to see at all? No, normally, you can’t really see it that way. Alright, come back here. I’m afraid we’re ripping his bladder so much too. I don’t want to go too crazy with it. We’ve got one in so I - we know he’s going to be drained, so I’m thinking that maybe we need to cut our losses here. And if you had to do a nephrostomy? Yeah, you could. Yeah, yeah. Okay, so let’s look - what we got? So here’s this. So I can - actually, we got that. There’s bladder neck. We really don’t want to get that any more than we already have so we can bring that together, and now we’re going to do this neourethra. Okay.
So typically with - with this defect, you have a urethral plate that you close where actually it appears that he has a urethra extending down into his - under his corporal bodies, and we’re going to basically do something of a cut to the light procedure here to see if we can get something to anastomose to the skin. So liver up - down like that. Is this all just urethra? No this is corpora. This is definitely corpora. This is corpora up here. Bovie. This is right there. Push, a little bit more, down here. Okay. Alright. Do you have a right angle? Actually, we might be able to get this through. Okay. Let me see a 5-0 Vicryl.
So what I would do is I put a stitch in here. This is like - this is like the everted ileum, right? Yeah. So we push it back in, and I’ve got a stitch on the other side that I can pull through and that everts the - that everts the mucosa. But I - but your c - your concern is correct because it looks like our defect is actually through the corpora around - or through the - through Buck’s fascia rather than through - it’s like we kind of came through the dorsal aspect of the - right, exactly, so - or the ventral aspect of the urethra. Yeah, right here is the defect. So - you can close that up. Yeah, yeah, yeah.
Or is it like intraperitoneal injury, and so you just need to loosely close it and then it’ll heal on its own? This? Yeah. This injury is not a big deal at all. This is actually just mucosa than anything else. We - we actually just undermined the mucosa here now that I’m looking at it. Now the question is is can I - do another one, or? No, it should be fine, but what I’m thinking of is how - can we burrow through there on this and cut through the light that way. Just seems like if that’s - I’m already through - all fibrotic... This isn’t - this isn’t - you’re talking about - where - I’m - I’m not seeing our lumen here. Right. Or are you just thinking that - that very tip there? Well, but I’m not going to do anything more to this. Yep. I’m going to close the bladder, put an SP tube in, and that’ll be it. And I’ll - and I’ll bring this out through a separate stab incision or something along those lines, so. Because at this point, I’m afraid I’m just going to - I’m going to - you know, he’s already been on the table for a long time, and I don’t want to keep trying to make this happen. We can always come back another day and do it.
Close this bladder real quick. We won’t close the whole thing. We’ll get it started, but the - but you guys don’t want me to put the SP tube in, right? Right, because we’ll do our ostomy. Should we do our ostomy now? Sure. Or do you want to get some of that closed? It doesn't - it - doesn't matter? It doesn’t matter. It doesn't matter. Okay. You guys go ahead. And then - can we bring him out of - then you can do whatever you need down there. Right, exactly. I’m going to do - I'll do a little bit more to the penis - do an SP, and it'll kind of - right - is in our incision. Well, what I’ve got to do is I’ve got to - I've got to cover the penis, I've got to close the bladder, put in an SP tube, and that's - and then bring the - and then bring the pelvis together. Mosquito.
So what I’ve done is I’ve brought the - the - the end of the corporal bodies, which are the erectile tissue, up so it can - you know, potentially be stimulated in the future when he gets older so he can potentially achieve orgasm, but the problem is is it’s covered - it’s obviously very raw looking and my concern is leaving it like this. Is it going to scar in some way that will – you know, make him unhappy or, even worse, reduce the sensation? Let’s see. That was maybe one too stitch – one stitch too much. Yeah, probably so. Scissors, please. Just - we’ve got to keep that open until – until we put the pubic symphysis stitch in. Okay.
So, let’s have a right angle clamp. Okay. Problem with that is this is the side of the bladder that’s more of a problem, but we can still bring it in this way. Let’s see here. Bovie. There’s not much of a space there for that bladder. Have that come out like that. So we’ll do that. And you want this out? And then we’re going to bring this through a separate stab incision as well. Unfortunately, I’m going to - I have to draw this across - I have this intraperitoneal coming this way. Okay. I mean, it’s not the biggest deal in the world. Obviously, I’d like to keep it extraperitoneal if you can but - yeah. I mean, we take out drains intraperitoneally all the time, but - just so you know. If you don’t have to, it’s nice. Right. Okay so there’s that. So you’re not going to bring that one up through your umbilicoplasty? This? Yeah. No, because like I said, I want to keep this in for a period of time - okay - and if we go through the – through the umbilicus it’s going to be hard to – okay, let that heal – yeah, exactly.
Exactly, so let’s do this. We got to bring this through too. Let me have the right angle back. You need to cut the end off that one then? Yep. Bovie. Okay. Actually, stop - let’s do it this way. Okay. I think I should be able to get that through. 5-0 Vicryl, please? Malecot we’ll sew in standard fashion. Do you have the – the Malecot stitched in there as well? Yes, I’ve got a purse string around it right now, so yeah. Okay, I wasn’t sure if you had anything in - internal as well. Oh, no, no, no. I haven’t stitched it into the bladder. I sure don’t want to sacrifice any more bladder than I have to. Sure. Let’s see if we can make this work like this. Okay.
Can I get a syringe? I just want to flush this real quick - make sure we don’t have any giant leaks here. Sure. Yeah, why not? You’re trying to flush this? Yep. Alright, here’s a blunt. You can flip it on it. I just tried it on the other. Great. Go ahead. Don’t cut it yet, but I want you to irrigate. That’s the reason why you do it. A little bit of a chimney here. Trying to preserve as much bladder as possible. This is a decent sized bladder, especially for a cloacal exstrophy patient - and despite everything that we did. Right. Just gently, gently – don’t – bend it? Yeah. A leak somewhere – there’s a little leak in the bottom there. It’s right here. Alright - here, okay. So those tiny ones are not - irrigate again. He’s going to - he had a – a pretty severe myelomeningocele and ki - chiari malformation, so. Something’s leaking low. Can you fill this up again? Is that a sixth hour? Basically. It’s not a full length, okay? That’s fine. One more time, gen - gently. Pickups. That looks pretty dry.
So this is where we’re going to put the stitch in, and then we’re going to abduct his legs – or adduct his legs, excuse me. Do we need to take the - the IO band off? Yep, we do. Alright, so let’s - and actually, we can also take a quick look at the myelomeningocele – or the lateral - does that all look okay? He’s been lying on that. It looks a little bit of ooze there. Okay. So can you retract in here for me? I’ve got the retractor. Now actually, if you hold the...
That’s not going through corpora, right? No, I think we’re - corpora is over here. We’re okay. Okay. There’s one. Let’s try the other side now. And those are some pretty good bites there, so. So I’m going to start tying down, and you just light that first. Time to see that suture. It is. This is the pubic symphysis stitch. It’s - this is a 2 – this is a number 2 - what we call a number 2. Want me to take that out? Yeah, go ahead. It’s alright, throw that around. So slowly bring the hips a little bit closer together. Okay - not so much, not so much. There we go. And can you snap that knot? Mosquito. We're - another one close. Okay, we’re good. If we can get this to hold, I think we’ll be set. Okay, one more. Good. Okay. Actually, what we can do is we’ll just cover it with xeroform. Okay – in a little bit? Yeah. Okay. Like that - and I do – I probably do a bunch of stitches because it – it does slip. A bunch of knots, you mean? Yeah, I’ll usually do like 6. Did it work? We’ll see. Go ahead and let go. It’s not perfectly opposed – but it will keep it from dehiscing? Yeah, I think that – yeah, they’re right next to each other, so I think we’re okay. I think we’re okay. So sorry, I think this – this hurt us. Are you doing one more? No, we’ll - we’ll just stick with that now. Let’s go ahead and close this. Yeah, that - you can feel that the - the tips are right next to each other there.
Skin hooks, and I’ll take an Adson with… So there’s one set, and I gave you some toys back. Yep. Another skin hook. With a Bovie. So this is - what we’re – what we’re doing here is separating the skin from the fascia so we can get a nice muscular closure. Nothing important there, right? Yeah, you’re good. I think all the way around you’ll be fine because the bladder’s deep in the pelvis now, so. That’s pretty good there. Let’s come around. Here’s…
Let’s see how we’re doing because I… I think as far as muscular closure – trying to see where – and that’s fascia there, and down here we’re kind of below and – right - that’s bladder. Right here and below is bladder neck, so. And that’s a pubic bone right there, so I don’t think you’re going to – I mean, we can close the fascia here but - so what I’m thinking is, you know, we’ll get – we’ll do some interrupteds, and you can see how this comes together. We’re closing the – we’re closing the - the fascia now. Hopefully, it stays together. I think the pelvic osteotomies were definitely key. And actually that Ethibond is a – does seem to be a nice stitch for that. Yeah.
So as we get a little bit lower, we’ll have to see what’s muscle, and what’s here. The bladder’s pretty far down, so – that – that - that’s bladder right there, so you’re - you’re – you’re good. So if that's - that's bladder there - below it, but you're good up there. Okay. If you just want to be in there, that’s totally fine. That’s okay there, right? Needle back - another stitch. Do we have some more 5-0 Vicryl because I’m going to have to do a couple more things down low? So - so now here is where we kind of get into this, and this is where – actually, I can - what I can do is I can define this for you right now. Let me see that 5-0. I’m – I’m guessing that, actually, I’m coming this over to there. Right, and this goes down - actually, I need the needle back - this can – this can come over. This all can come like here. That’s bladder right? Well, but you’re on top of it - not really because this is up here is fine and I think you can – I can think – I think you can bring that to there. Bovie. I just want to free up a little bit there because I think when you pull that up – let’s show them. And then this stuff you can bring over.
So as far as muscle - I’m just trying to see what we have muscular-wise because that’s – you have that – so that is – don’t want him to... Right there - yep, you're clear right there. You're clear all the way up to here basically. Okay, so actually - but I – but I need to use this skin to resurface down there so. Okay, so you don’t want me to take that, so I can take - and what is this here? Below that? Oh, that’s the umbilical artery. Okay. Yep. That’s right. So I can come – if I come - let’s see. We don’t want to get like that. So then that’s bladder there. You’re not incorporating bladder but – but I think, what I’d like to do is see if I can get - that stuff? Yeah. Yeah, I think that makes sense. So then I can bring this. I think you take all of that. Yep. Yeah.
Snap scissors. That looks pretty good. I don’t know if I need to do another one beyond that because the – because I don’t want him to herniate down low, but I guess the worst case – you know, his bladder is there, right? So I - I think - you know, this – this muscle is closed. Bladder is here. Yeah, I don’t think he’s going to herniate down that way. I think – okay, so what I can do - it’s going to be pretty hard to do. Like this one next. Good. That one next. Good. So – you have a back or the – just the – got this DeBakey? Okay, so you can pull that way and that way. Good. And then - looks pretty darn good, all things considered.