From
StayCurrentMD
Technique: Laparoscopic Assisted Pull-through for Hirschsprung's Disease
With Dr. Steve Rothenberg
Chapter 1 of 6 · Surgical Management
Port placement
Patient positioning and port placement
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
The key to mesenteric dissection is staying exactly adjacent to the colon wall to prevent injury to surrounding structures.
Because all heat and energy remains between the jaws of the sealer, there is no danger in injuring surrounding structures by brushing aside them with the sealer.
Small perforating vessels are grasped, sealed, and then pulled down off the rectal wall during circumferential dissection.
Dissection at the peritoneal reflection uses the same technique of grasping the peritoneal reflection and small perforating vessels and pulling them down off the colon.
The 3 millimeter sealer allows dissection of vessels and mobilization of tissue around the colon without risk of pass-pointing, unlike the 3 millimeter hook which was previously the preferred mode of dissection.
Using the 3 mm sealer eliminates the need for instrument changes with the right hand throughout the case.
Carrying the laparoscopic dissection down to the pelvic floor limits the amount of transanal dissection necessary and decreases the risk of injury to the external sphincter.
Because there is no energy spread from the tips of the 3 mm sealer, it is safe for the instrument to be adjacent to the bladder, vagina, prostate, and other surrounding structures.
Energy being only between the jaws of the instrument diminishes the risk of injury to the ureters, vas deferens, and other vital structures.
The preferred timing is to perform this operation in the newborn period prior to discharge to home, though it is acceptable if the child tolerates rectal irrigations to let them grow.
With current technology, the operation is considered extremely safe in the newborn period.
For the transanal dissection, traction stitches are placed inside the anus just proximal to the dentate line and then out to the skin, slightly inverting the anus so the dentate line can be clearly visualized.
Between 4 to 8 sutures are used to evert the anus.
A mucosal incision is made with hand cautery 2 to 3 millimeters proximal to the dentate line and crypt.
The key to the transanal portion is that it should all take place externally to the anus.
The laparoscopic dissection down to the pelvic floor allows the transanal dissection to be carried out outside of the anus, so no retractors are ever placed within the external sphincter which may cause these muscles to be damaged.
Sharp dissection is preferred to mobilize the submucosal space, although blunt dissection can also be used.
Performing the dissection external to the anus protects the external sphincter muscles and improves the chance of good continence.
The colon is divided 5 to 6 centimeters above the biopsy site, which is 5 centimeters above the obvious transition zone.
The coloanal anastomosis is performed with 12 to 16 sutures total, placing 3 to 4 additional sutures in each quadrant after the initial 4 quadrant stay sutures.
Vicryl suture is used for the anastomosis in newborns.
This operation took 70 minutes.
The child was left without a nasogastric tube and started stooling the morning following surgery.
The patient was started on feeds less than 24 hours after the procedure.
The anastomosis is calibrated with a 12 Hegar dilator at the end of the procedure.
Gauze packing is placed in the anus at the end of the procedure.
The JRS 3 millimeter sealer is used as the primary mode of dissection for laparoscopic-assisted pull-through in Hirschsprung's disease.
The patient was a newborn weighing 3.2 kg.
A super umbilical ring incision is used for small newborns to place the Veress needle and 4 mm trocar, with care taken to avoid the umbilical vein by placing the trocar just to the left of midline.
A full thickness biopsy is obtained from the muscular wall approximately 5 centimeters above the transition zone between the distal sigmoid and rectum.