, Bala Eradi2 and Marc A. Levitt3
(1)
Department of Paediatric Surgery, Southampton Children’s Hospital, Southampton, UK
(2)
Department of Paediatric Surgery, Leicester Royal Infirmary, Leicester, UK
(3)
Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, USA
Abstract
Laparoscopic-assistance for Hirschsprung disease (HD) pullthrough procedures has increased in popularity. This change has been associated in the UK, for example, with a shift from the Duhamel procedure, which had been performed most frequently, to an endorectal pull-through (ERPT) procedure that is being practiced more widely [1]. The concept of the transanal only approach was put forth by Langer and de la Torre, but this was using a Soave-like dissection, a problem noted by Swenson himself who originated this concept with the original repair for HD [2]. The use of the Swenson-like technique for ERPT has been popularized by Levitt and colleagues [3], who reported a series of 67 patients in 2013. The advantages of this approach are its simplicity, preservation of the pelvic nerves, and avoidance of the obstructing muscle cuff that may occur after the Soave-Boley procedure [4]. The procedure can be undertaken as a purely transanal operation for cases in which rectosigmoid aganglionosis is obvious from the contrast study, but initial laparoscopic colonic mobilization and biopsy are preferred in most cases.
Keywords
Hirschsprung diseaseSwenson-like pull-throughLaparoscopy30.1 General Information
Laparoscopic-assistance for Hirschsprung disease (HD) pullthrough procedures has increased in popularity. This change has been associated in the UK, for example, with a shift from the Duhamel procedure, which had been performed most frequently, to an endorectal pull-through (ERPT) procedure that is being practiced more widely [1]. The concept of the transanal only approach was put forth by Langer and de la Torre, but this was using a Soave-like dissection, a problem noted by Swenson himself who originated this concept with the original repair for HD [2]. The use of the Swenson-like technique for ERPT has been popularized by Levitt and colleagues [3], who reported a series of 67 patients in 2013. The advantages of this approach are its simplicity, preservation of the pelvic nerves, and avoidance of the obstructing muscle cuff that may occur after the Soave-Boley procedure [4]. The procedure can be undertaken as a purely transanal operation for cases in which rectosigmoid aganglionosis is obvious from the contrast study, but initial laparoscopic colonic mobilization and biopsy are preferred in most cases.
30.2 Working Instruments
3-mm Ports and instruments: hook diathermy, graspers, needle holders.
30° camera (5 or 3 mm)
Lone Star retractor and needle-point (Lone Star Medical Products, Houston, TX); hand-held monopolar diathermy is used for the transanal approach.
30.3 Positioning, Port Siting and Ergonomic Considerations
For laparoscopic mobilization, the patient is positioned at the foot of the table and turned 90°. This allows the operating surgeon to stand at the patient’s right shoulder facing the pelvis, and the assistant can stand on the patient’s left side. Full skin preparation of the lower limbs and abdomen is undertaken, and the legs and feet are wrapped in crepe bandage and bio-occlusive dressing sheets to allow repositioning intraoperatively. The laparoscopic stack is positioned at the feet end of the patient. Urethral catheterization is required.
For the transanal approach, the prone position is preferable because this facilitates dissection between the rectum and urethra in males (the rectum and vagina in females). For laparoscopic dissection/biopsy and the transanal approach, the patient can be positioned supine with the legs elevated.
30.4 Relevant Anatomy
Dissection is done close to the rectal wall to avoid damage to the pelvic nerves. If laparoscopic abdominal mobilization is undertaken, both ureters (and vasa deferens in males) should be identified and preserved.
30.5 Surgical Technique
30.5.1 Laparoscopic Colonic Mobilization and Biopsy
The patient is initially positioned supine, as described above. Three or four ports are used. In small infants it is helpful to place these all above the umbilicus to allow more space for the instruments. The camera port is placed high in the epigastrium, to the right of the midline (and falciform ligament). Two lateral ports (3 mm) are placed. A fourth port placed in the left upper quadrant can be helpful to grasp the sigmoid colon. Insufflation pressure of 8–10 mmHg and a flow of 2–3 L/min are used. The patient is positioned head-down so that the small bowel can be displaced out of the pelvis. The rectosigmoid colon is evaluated, and the likely transition zone is identified. There are two options for confirmatory colonic biopsy with frozen section histologic evaluation. A seromuscular colonic biopsy can be taken from the taenia coli (Figs. 30.1, 30.2, 30.3, and 30.4) with a later full-thickness biopsy at the end of the pull-through. The alternative is to take an initial full-thickness colonic biopsy and suture the enterotomy closed (either laparoscopically or by exteriorizing the colon through one of the port sites). This latter technique avoids the pitfall of ganglion cells being noted in the muscular layer when there are hypertrophic nerves in the submucosal layer.
Colonic mobilization is started by elevating the sigmoid colon by grasping the mesenteric edge of the bowel. Hook monopolar diathermy is used to fashion a window in the mesentery (Fig. 30.5). Further mesenteric division is continued proximally and distally (Fig. 30.6). Great care must be taken to preserve the sigmoid mesenteric arcade and to ligate the inferior mesenteric artery high near the aorta. This will allow mobility of the colonic pull-through segment without compromising its blood supply. The lateral colonic peritoneal attachments are displayed by drawing the colon medially and are again divided using hook diathermy (Fig. 30.6). The left ureter should be identified at this stage. If need be, the splenic flexure is taken down. Dissection is continued (medially and laterally) distally to the peritoneal reflection (Figs. 30.7 and 30.8), together with identification of the right ureter. In males, the vas deferens should be identified at the level of the peritoneal reflection. Mobilization of the rectum beneath the peritoneal reflection should be to the deep pelvis, making the transanal part required relatively minimal. For a transition zone proximal to the mid-transverse colon, an open approach is performed to carefully delineate the mesentery and to derotate the colon if necessary.
