Laparoscopic pull-through for Hirschsprung disease updated 2024
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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
A biopsy taken from the mid to upper sigmoid confirms ganglion cells
Dissection begins on the upper rectum, carefully removing fat and dissecting at the peritoneal reflection
The lower sigmoid segment appears leathery while the more proximal sigmoid appears healthy
Care must be taken to check for the left ureter during dissection
The arcade to the biopsy site is preserved and the mesentery is taken adjacent to the bowel distal from this location
A good marginal branch from the IMA must be ensured, with everything distal to this branch dissected with ligature
The intended section of bowel must easily reach the perineum for the pull through to the coloanal anastomosis
With legs in lithotomy position, Lone Star pins are placed to expose and protect the anal canal
The purple line of Lee is marked 0.5 centimeters proximal to the dentate line, which is hidden by the pins
Dissection is performed in a full thickness, Swenson-like plane
The transanal dissection quickly breaks through to the location of the previous laparoscopic dissection
The bowel is pulled through maintaining its orientation and marked to avoid twisting
The anastomosis is performed with seromuscular bites to the sphincter, then a second layer mucosa to mucosa
Pulling apart opposing mosquito clamps and suturing between them takes away any size discrepancy during anastomosis
A 5 millimeter trochar is used for umbilical access to begin the case
The camera is moved to a port site at the right upper quadrant to maximize exposure to the view of the pelvis
The operating surgeon should stand at the patient's right shoulder
Laparoscopy is used to do the leveling biopsy, bringing the sigmoid out the umbilical port for an extracorporeal full thickness biopsy
Once the level is confirmed, laparoscopy is used to take down the attachments of the left colon from the left retroperitoneum and dissect into the deep pelvis
The mesenteric arcade distal to the biopsy site is taken while preserving the sigmoid arcade to the location of the intended pull through
The purple line of Lee is traced 0.5 centimeters proximal to the crypts, preserving the anal canal
Silk sutures are placed which facilitate a circumferential dissection into the Swenson plane
The bowel is mobilized full thickness until the prior laparoscopic dissection is reached, allowing the rectosigmoid to be pulled through to the biopsy site