(1)
Department of Paediatric Surgery, Royal Hospital for Sick Children, 9 Sciennes Road, Edinburgh, EH9 1LF, UK
Abstract
Laparoscopic Duhamel pull-through is a surgical option in typical Hirschsprung disease (HD). Primary laparoscopic Duhamel pull-through is possible in the newborn who responds to washouts. Effective and ongoing washouts are imperative in management preoperatively and in preparation for surgery. Limited bowel prep (twice daily washouts and low-residue clear fluid diet for 24 h) is sufficient bowel preparation in most cases. The presence of a stoma does not preclude a laparoscopic approach but does make it more technically difficult and the advantages are fewer (e.g., previous laparotomy scar or adhesions). If sited advantageously, the stoma can be brought down for the pull-through. Otherwise a separate stoma closure is also required. Intraoperative frozen section is required to determine the correct level of ganglionic bowel; the appearance of a visible transition zone is not always seen, nor is accurate indication of the level of ganglionic bowel. Antibiotics are given at induction.
Keywords
Hirschprung’s diseaseLaparoscopyDuhamel pull-throughAganglionosis28.1 General Information
Laparoscopic Duhamel pull-through is a surgical option in typical Hirschsprung disease (HD). Primary laparoscopic Duhamel pull-through is possible in the newborn who responds to washouts. Effective and ongoing washouts are imperative in management preoperatively and in preparation for surgery. Limited bowel prep (twice daily washouts and low-residue clear fluid diet for 24 h) is sufficient bowel preparation in most cases. The presence of a stoma does not preclude a laparoscopic approach but does make it more technically difficult and the advantages are fewer (e.g., previous laparotomy scar or adhesions). If sited advantageously, the stoma can be brought down for the pull-through. Otherwise a separate stoma closure is also required. Intraoperative frozen section is required to determine the correct level of ganglionic bowel; the appearance of a visible transition zone is not always seen, nor is accurate indication of the level of ganglionic bowel. Antibiotics are given at induction.
28.2 Working Instruments
Ports of 5-, 10-, or 12-mm (depending on the size of the endoscopic stapler; a Step-port (Medtronic; Minneapolis, MN, USA) can be used to incrementally increase the size as required).
3-mm or 5-mm Port × 2
30° telescope
Hook diathermy
Needle holders
Dissection scissors
Johan (or other fenestrated grasping) and Maryland forceps
Suction and irrigation are helpful
Endoscopic articulating stapler (for abdominal anastomosis)
Endoscopic linear stapler (for rectal anastomosis) 45 mm
Harmonic ultrasound dissector or LigaSure bipolar (Medtronic-Covidien, Minneapolis, MN, USA) (alternative energy sources)
28.3 Positioning, Port Siting, and Ergonomic Considerations
The infant is placed in a supine position and should be put at the foot end of the operating table. The legs should be prepped and draped to allow them to be raised and positioned for the transanal dissection. Urethral catheterization is required.
A 5-mm supra- or subumbilical incision is used for a primary port. Pneumoperitoneum is established to 8 mmHg pressure; this can be increased to 10 mmHg if required and tolerated. A small degree of head-down tilt increases the exposure of the pelvis and rectum.
Two further working instruments are placed on the right and left sides of the abdomen to allow triangulation. The right-sided port may need to be either a 5- or 10-mm size port, depending on the diameter of the reticulating stapler used.
28.4 Relevant Anatomy (Figs. 28.1 and 28.2)
Fig. 28.1
Anatomy of the pelvis. The anatomy of the male pelvis showing the rectum and bladder. The ureters, approaching the base of the bladder, are seen
Fig. 28.2
The initial view in a female pelvis. The aganglionic contracted rectum is obvious in this patient. The conical shaped transition zone is also seen leading up to the sigmoid colon
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