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2010 | 82 | 12 | 687-693

Article title

Traumatic Cloacal Defect, the Warren Flap Revisited a Description of the Technique and Review of the Literature


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Traumatic cloacal defects are rare and are characterised by complete dehiscence of the anterior sphincter complex, the perineal body and lower portion of the rectovaginal septum. Techniques of repair range from simple tissue apposition to complex flap reconstruction. We report a series of patients treated by a ‘Warren flap’.Methods. A review of four patients undergoing Warren flap repair for traumatic cloacal defect.Results. The Warren flap was performed with minimal complications. Patients were discharged within 2 days. Minor wound infections occurred in all four cases. At median follow up of 7.5 months (range 3-10 months) all patients had significantly improved continence (Vaisey score median 16 pre-op to 3 post-op) and sexual function.Conclusions. The Warren flap procedure utilises techniques and planes that are familiar to the colorectal surgeon, and is associated with rapid and safe recovery and good early postoperative function. It is a useful reconstructive technique for this complex injury.








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1 - 12 - 2010
23 - 2 - 2011


  • Dewsbury and District Hospital, Dewsbury, United Kingdom
  • Northern General Hospital, Sheffield, United Kingdom
  • Northern General Hospital and Faculty of Health and Wellbeing, Sheffield Hallam University, United Kingdom
  • Northern General Hospital, Sheffield, United Kingdom


  • Sultan AH, Kamm MA, Hudson CN et al.: Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ 1994; 308: 887-91.[PubMed]
  • Venkatesh KS, Ramanujam PS, Larson DM et al.: Anorectal complications of vaginal delivery. Dis Colon Rectum 1989; 32: 1039-41.[PubMed][Crossref]
  • Abcarian H, Orsay CP, Pearl RK et al.: Traumatic cloaca. Dis Colon Rectum 1989; 32: 783-87.[Crossref][PubMed]
  • Nicholls J: Sphincter repair for incontinence. Colorectal Dis 2009; 11: 545-46.[PubMed][Crossref]
  • Conaghan P, Farouk R: Sacral nerve stimulation can be successful in patients with ultrasound evidence of external anal sphincter disruption. Dis Colon Rectum 2005; 48: 1610-14.[PubMed][Crossref]
  • Jarrett ME, Dudding TC, Nicholls RJ et al.: Sacral nerve stimulation for fecal incontinence related to obstetric anal sphincter damage. Dis Colon Rectum 2008; 51: 531-37.[Crossref][PubMed]
  • Melenhorst J, Koch SM, Uludag O et al.: Is a morphologically intact anal sphincter necessary for success with sacral nerve modulation in patients with faecal incontinence? Colorectal Dis 2008; 10: 257-62.[WoS][PubMed][Crossref]
  • Chan MK, Tjandra JJ: Sacral nerve stimulation for fecal incontinence: external anal sphincter defect vs. intact anal sphincter. Dis Colon Rectum 2008; 51: 1015-24; discussion 1024-15.[Crossref]
  • Kaiser AM: Cloaca-like deformity with faecal incontinence after severe obstetric injury-technique and functional outcome of ano-vaginal and perineal reconstruction with X-flaps and sphincteroplasty. Colorectal Dis 2008; 10: 827-32.[PubMed][Crossref][WoS]
  • Venkatesh KS, Ramanujam P: Surgical treatment of traumatic cloaca. Dis Colon Rectum 1996; 39: 811-16.[PubMed][Crossref]
  • Draganic B, Solomon MJ: Island flap perineoplasty for coverage of perineal skin defects after repair of cloacal deformity. ANZ J Surg 2001; 71: 487-90.[Crossref][PubMed]
  • Block IR, Rodriguez S, Olivares AL: The Warren operation for anal incontinence caused by disruption of the anterior segment of the anal sphincter, perineal body, and rectovaginal septum: report of five cases. Dis Colon Rectum 1975; 18: 28-34.[Crossref][PubMed]
  • Warren JC: A new method of operation for the relief of rupture of the perineum through the sphincter and rectum. Trans Am Gynaecol Soc 1882; 24.
  • Hakelius L: Reconstruction of the perineal body as treatment for anal incontinence. Br J Plast Surg 1979; 32: 245-52.
  • Hollingshead JR, Warusavitarne J, Vaizey CJ et al.: Outcomes following repair of traumatic cloacal deformities. Br J Surg 2009; 96: 1082-85.
  • Young CJ, Mathur MN, Eyers AA et al.: Successful overlapping anal sphincter repair: relationship to patient age, neuropathy, and colostomy formation. Dis Colon Rectum 1998; 41: 344-49.[Crossref][PubMed]
  • Altomare DF, Rinaldi M, Bucaria V et al.: Overlapping sphincteroplasty and modified lotus petal flap for delayed repair of traumatic cloaca. Tech Coloproctol 2007; 11: 268-70.[PubMed][Crossref]
  • Merces RL, Pisi PH, Balestrim Filho A et al.: Surgical treatment of traumatic cloaca. Acta Cir Bras 2008; 23: 105-07; discussion 107.[WoS][Crossref][PubMed]

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