PMC6611720_01
A 2-year-old girl with complete colonic duplication on top of anorectal anomaly. The upper row demonstrates investigations performed before reconstruction: (
A
) contrast studies through the two distal "colostomy" stomas demonstrating one posterior colon and rectum (R1) terminating by the neo-anus, and another anterior colon and rectum (R2) terminating into the vagina (Vg); (
B
) and (
C
) midsagittal and axial MRI (T2-WI), respectively, demonstrating the orientation of both recti (R1 and R2) in relation to each other and to other pelvic organs (UB, urinary bladder). Note the injection of gel through both recti to facilitate their identification in MRI by the hyperintense signal of the gel in T2-WI. The lower row demonstrates pelvic MRI anatomy following reconstruction (after excision of anterior rectum R2, and closure of colostomy); (
D
) midsagittal plane; (
E
) axial plane. MRI, magnetic resonance imaging; WI, weighted image.
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 Diagnostic workup before definitive repair: we performed contrast X-ray studies ( Fig. 1A ) and pelvic magnetic resonance imaging (MRI; Fig. 1B and C ). Injection of contrast through the distal mucous fistulae revealed one posterior colon and rectum (R1) terminating by the neoanus, and another anterior colon and rectum (R2) terminating via a rectovaginal fistula ( Fig. 1A ). MRI studies revealed no associated spinal anomalies; and helped to complete the picture by defining the three-dimensional (3D) orientation of the double colon and rectum in relation to other pelvic soft tissue structures ( Fig. 1B and C ).  A follow-up MRI has been prescribed to check for postreconstruction pelvic anatomy ( Fig. 1D and E ).
Intraoperative photos and diagram representing extra-mucosal excision of the antimesenteric distal colon (C2) and rectum. (
A
) The distal colon to be excised (C2) was incised along its free antimesenteric border; (
B
) submucosal injection of adrenaline/saline solution (1/200,000) to control bleeding and elevate the mucosa (hydrodissection); (
C
) stripping of the mucosa off this distal colon and rectum; (
D, E
) the continuity of the fecal stream was then restored by anastomosing the proximal double colonic lumens with the retained distal colon (C1) in a Y-shape fashion. Note the limited terminal septotmy for the common wall between the proximal double colonic lumens in (
D
).
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The distal colon to be excised was incised along its free antimesenteric border ( Fig. 2A ), followed by submucosal injection of adrenaline/saline solution (1/200,000) to control bleeding and elevate the mucosa (hydrodissection; Fig. 2B ). Stripping the mucosa off this distal colon and rectum was then applied down into the pelvis; the stripped mucosa was transfixed and excised at its lower end communicating into the vagina ( Fig. 2C ). The continuity of the fecal stream was then restored by anastomosing the proximal double colonic lumens with the retained distal colon and rectum in a Y -shape fashion ( Fig. 2D and E ). Before that, a 7 cm linear cutting stapler was applied to the distal end of the common wall between the proximal double colonic lumens (limited septotomy), converting it into a single wide lumen that could be anastomosed to the single distal colon ( Fig. 2D ).