(1)
Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh, UK
Abstract
Surgical correction of Hirschsprung disease can be achieved with a primary, one-stage procedure. The laparoscopy-assisted approach allows for levelling colonic biopsies with proximal colonic and mesorectal dissection. It prevents excessive retraction of the sphincter mechanism, and direct visualisation ensures that the pulled-through portion of bowel has not been twisted.
Keywords
LaparoscopySoave pullthroughHirschsprung diseaseSerosubmucosal biopsies29.1 General Information
Surgical correction of Hirschsprung disease can be achieved with a primary, one-stage procedure. The laparoscopy-assisted approach allows for levelling colonic biopsies with proximal colonic and mesorectal dissection. It prevents excessive retraction of the sphincter mechanism, and direct visualisation ensures that the pulled-through portion of bowel has not been twisted.
29.2 Working Instruments
5-mm Hassan port
30° short telescope
3.5-mm port (×2)
3-mm Johan forceps
3-mm Maryland forceps
3-mm Metzenbaum scissors
Hook diathermy
29.3 Preparations, Positioning, Port Siting, and Ergonomic Considerations
All patients undergo rectal irrigation preoperatively. General anaesthesia is induced, a bladder catheter is inserted, and parenteral antibiotics are given.
The patient is positioned transversely across the operating table, close to the bottom edge, to allow for a full range of movement of laparoscopic instruments on the patient’s right side. The head rotates towards the left side, and all equipment related to anaesthesia should flow back towards the top end of the table (Fig. 29.1).
Fig. 29.1
Patient positioning
A diathermy plate is placed high on the infant’s back, and total body skin preparation is applied from nipples to knees, extending onto the perineum and lower back. The lower limbs are wrapped in sterile wool placed in sterile sticky plastic sheets, and the feet are permitted to dangle over the table edge (Fig. 29.2).
Fig. 29.2
(a–c) Preparation of the patient
The surgeon and assistant stand above the infant’s head, facing the monitor, which is placed beyond the infant’s feet. The scrub nurse stands behind the surgeon and assistant (Fig. 29.3).
Fig. 29.3
Position of the surgeon and assistants
Port positions: A single rubber-shod 5-mm port is inserted in the right upper quadrant by direct open dissection through the rectus muscle. Mini lap dissectors are particularly helpful in this confined space, and sutures are placed in each abdominal layer as it is identified and incised (Fig. 29.4). The dissection must be kept perpendicular to the skin. Two further 3.5-mm ports are inserted on the right and left sides under laparoscopic vision (Fig. 29.5). A pneumoperitoneum is achieved with a flow rate of 1l/min and 8 mmHg pressure.
Fig. 29.4
Placement of a 5 mm port in the right upper quadrant
Fig. 29.5
Placement of two 3.5 mm ports on the right and left sides
29.4 Relevant Anatomy
A clear view of the pelvis is needed to view the distal colon and rectum. Identify the bladder (with catheter), peritoneal reflection, anterior wall ligaments, and the uterus and ovaries in female patients. Proximal dilated bowel helps to localise the possible transition zone and sites where biopsy specimens should be taken (Fig. 29.6).
Fig. 29.6
Proximal dilated bowel helps to indicate sites for biopsy
29.5 Surgical Technique
- 1.
Levelling biopsies. Three serosubmucosal biopsies are taken: above, within, and below the possible transition zone. The wall of the colon is lifted with fine-tipped forceps (Maryland) in the left hand (Fig. 29.7a), and scissors are used to make a single bite (Fig. 29.7b) in this elevated portion. A V-shaped tongue of colonic wall is seen, and the tip of the V is lifted, with precision, by the fine-tipped forceps in the left hand. Develop the biopsy on each side of the V using small snips and spreading, undermining movements of the scissors. When enough colonic wall has been dissected, cut across the base and send for frozen section (Fig. 29.7c)
