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quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "while the AP view might misleadingly suggest an underdeveloped sacrum, the lateral view typically provides a more accurate representation. The pelvic tilt can distort the appearance of the sacrum and coccyx in the AP view, leading to a falsely low sacral ratio. The lateral view, however, allows for a more reliable calculation by minimizing distortions caused by patient positioning"

quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "It is crucial not to chase the anteriorly directed fistula toward the scrotum, as it runs parallel to the urethra. Attempting to trace this fistula surgically could lead to significant complications, including spongiosum bleeding and urethral injury. Instead, the focus should be on mobilizing the distal rectum and avoiding dissection of the anterior rectal wall to avoid a urethral injury."

quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "A recent study from the ARM-Net registry highlights the need for sufficient screening and vigilant management of high-grade VUR in ARM patients. This study underscores the fact that despite normal kidneys on US, a significant proportion of patients may still have high-grade VUR, necessitating prophylaxis. All patients with ARM should have a newborn screen renal US and, in most, a follow-up VCUG should be done to assess for VUR."

quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "If the frozen section reveals active enterocolitis in a ganglionated bowel section without nerve hypertrophy, diversion should be considered as active enterocolitis can increase the risk of anastomotic complications such as stricture and dehiscence."

quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "During the operation for HD, frozen section biopsies are used. Frozen section biopsies cannot diagnose HD, but they can rule it out. They only capture one section of the bowel and may be useful intraoperatively for confirming the presence of ganglionated bowel for an anastomosis or a stoma site. Permanent sections are the gold standard for diagnosis and are used to determine transition zones. As previously mentioned, the distribution of ganglion cells is irregular at the transition zone, and multiple slices (>100) need to be evaluated circumferentially as a single slice could capture one of the few ganglion cells within a transition zone and falsely lead to a diagnosis of normal colon or the reverse could occur. Frozen section might not see ganglion cells which in fact are nearby, and have the clinician draw the wrong conclusion that the bowel is aganglionic. Frozen section is subject to artifact from cracking of the tissue and can lead to the pathologist not being able to see ganglion cells which are in fact present. Permanent sections also offer a better appreciation and measurement of nerve hypertrophy. They take a longer time to process and are not available intraoperatively"

quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "Anorectal manometry is sometimes used to diagnose HD; however, its diagnostic accuracy is limited in children under the age of 12 months. It is a helpful adjunct in diagnosing older children who struggle with constipation due to a delayed diagnosis of HD. One of the characteristics of HD is that patients cannot relax their internal anal sphincter in response to rectal distension, otherwise known as the rectoanal inhibitory reflex (RAIR). Anorectal manometry can screen for the absence of this reflex, which is typical of HD. If the RAIR is absent, a rectal biopsy to assess for HD should be done."

Quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "The main differential of surgical diagnoses for an infant with a distal bowel obstruction are: • HD • Neonatal small left colon • Anorectal malformation • Jejuno-ileal atresia • Meconium ileus • Meconium plug syndrome Some medical causes of colonic distension include: • Hypothyroidism • Magnesium sulfate effect • Opiate effect • Milk protein allergy"

quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "Vaginal loss or acquired vaginal atresia, like urethral loss, occurs from ischemia related to excessive dissection and tension. When UG separation is required, it is important to maintain the vaginal blood supply from the lateral attachments bilaterally. For this reason, older techniques such as the vaginal switch have been abandoned. Optimal mobilization of the vagina is achieved by full separation from the common channel and fully dividing the central pelvic and retroperitoneal attachments posteriorly. The blood supply then depends on the round ligaments from both sides. A vaginal length of 4 cm is predictive of a successful native vaginal pull-through. When the Müllerian structures are smaller or absent, delayed vaginal reconstruction or bowel vagina replacement should be considered. If a bowel neovagina is used to bridge the gap to the perineum, this could be removed later in life with a pull-through, at that time, of the native vagina."

quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "Urethral loss or urethrovaginal fistula can occur due to ischemia related to over-dissection of the common channel. If the surgeon underestimates the common channel length and begins a TUM dissecting the anterior urethra but then realizes intraoperatively that there is insufficient mobilization to reach the perineum, changing to a UG separation and dissecting the posterior urethral wall risks significant ischemia of the now circumferentially dissected common channel. Such complications can lead to an acquired bladder neck closure and the need for a Mitrofanoff."

quote from "Pediatric Colorectal Conundrums: Case Studies: From Fundamental to Advanced (Pediatric Colorectal Surgery)" by Marc Levitt, Thomas Xu, Hussein Wissanji - "When the common channel is <3 cm, it is possible to mobilize the UG complex as a unit to the perineum, the TUM. In general, a urethral length of >1.5 cm is required to avoid urine leakage and to avoid pulling down the bladder neck out of the urogenital diaphragm with the mobilization. When the length of the common channel is >3 cm or the urethra is <1.5 cm, a UG separation is utilized, leaving the common channel untouched and adding to it the native urethra. With the UG separation, the vagina and rectum are dissected off of the common channel and mobilized to bring them each down to the perineum independently. When the common channel is >3 cm, a UG separation is required to gain the necessary mobilization for the vagina to reach the perineum. After separation, the common channel is repaired, and the urethra and common channel together become the new urethra now with adequate length."