From
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Laparoscopic Duhamel: Pediatric Surgery Difficult Cases 2013
Part of
Constipation 10 items
Chapter 1 of 3 · Surgical Management
Technique presentation
Presentation of the New Laparoscopic Duhamel Technique
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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
Doing everything extraperitoneally is nice as an approach.
All of these techniques are good adjuncts to the armamentarium for Hirschsprung's disease, and knowing more techniques allows tailoring to appropriate patients.
One of the mistakes people make when doing a transanal pull-through is to stretch the sphincters and do the operation on the inside; it should be done by pulling everything out and doing it on the outside without stretching the sphincters.
With increased experience in laparoscopic Duhamel, surgeons no longer bring the colon outside to transect it and leave a pretty short stump.
The stump can be trimmed later on before closing down, avoiding the need to overstretch the anus.
Using the end of GIA stapler for making the side-to-side anastomosis allows the procedure to be performed even in neonates at a very early age.
The new Duhamel pull-through was designed to eliminate the septic intraabdominal step, avoid intraabdominal sutures, determine the length of the residual stump, and assure a more secure colorectal anastomosis.
The posterior rectal wall incision is made 1.5 centimeters from the dentate line.
The retrorectal tissue is easily dissected, allowing access to the retrorectal space to the sacral promontory.
Dissection is performed along the lateral walls of the rectum approximately 50% of the circumference of the posterior rectal wall.
Entry into the retrorectal space from the abdomen is basically a bloodless process.
The level at which to cut the colon is defined by pathologic markers intraoperatively by frozen section or by mapping a transition zone with previous suction biopsies.
The anastomosis is completed using the Martin technique and modification, leaving a very ample window with minimal chance of stenosis.
At 6 months postoperatively, the residual pouch is approximately 3 centimeters in an asymptomatic patient.
Problems that can occur include accumulation of feces, constipation, and fecal impaction when the stump is left too long.
The technique is recommended for all pediatric patients, including patients with very dilated colons, and is reproducible, easy, and fast with minimal incidence of constipation and stenosis.