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29 Laparoscopic-Assisted Soave Pullthrough for Hirschsprung Disease
213
Fig. 29.2 (a–c)
Preparation of the patient
a
b
c
214
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A.J. McCabe
Fig. 29.3 Position of the surgeon and assistants Fig. 29.4 Placement of a 5 mm port in the right upper quadrant
Fig. 29.5 Placement of two 3.5 mm ports on the right and left sides
29 Laparoscopic-Assisted Soave Pullthrough for Hirschsprung Disease
29.4 Relevant Anatomy
A clear view of the pelvis is needed to view the distal colon
and rectum. Identify the bladder (with catheter), peritoneal
reflection, anterior wall ligaments, and the uterus and ovaries
in female patients. Proximal dilated bowel helps to localise
the possible transition zone and sites where biopsy specimens should be taken (Fig. 29.6).
215
Fig. 29.6 Proximal dilated bowel helps to indicate sites for biopsy
216
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A.J. McCabe
29.5 Surgical Technique
1. Levelling biopsies. Three serosubmucosal biopsies are
taken: above, within, and below the possible transition
zone. The wall of the colon is lifted with fine-tipped for-
ceps (Maryland) in the left hand (Fig. 29.7a), and scissors
are used to make a single bite (Fig. 29.7b) in this elevated
portion. A V-shaped tongue of colonic wall is seen, and
the tip of the V is lifted, with precision, by the fine-tipped
forceps in the left hand. Develop the biopsy on each side
of the V using small snips and spreading, undermining
movements of the scissors. When enough colonic wall
has been dissected, cut across the base and send for fro-
zen section (Fig. 29.7c)
2. Colonic mobilisation is begun where ganglionated
bowel is confirmed in the rectosigmoid region. Sigmoid
colon is lifted towards the anterior abdominal wall with
a grasper in the left hand (Fig. 29.8). The mesentery is
inspected for a suitable mesenteric “window,” and the
hook diathermy, in the right hand, is used to develop a
small hole in the mesentery, through which the left-
handed forceps can then be placed closed and lifted
upwards to hold the colon more easily (Fig. 29.9). From
the window, the mesenteric vessels are individually dia-
thermied with the hook, staying close to the colonic
wall, working towards the pelvis (Fig. 29.10). When the
peritoneal reflection is reached, a circumferential inci-
sion is made and the mesorectum is dissected as far
down into the pelvis as possible (Fig. 29.11). It is worth
checking that the vascularised proximal bowel to be
pulled through, reaches comfortably into the pelvis
(Fig. 29.12). During dissection, take time to ensure that
both ureters are seen, and not inadvertently pulled up
into the dissection plane.
3. Repositioning. The legs are elevated over the head and
secured with clips onto the drapes (Fig. 29.13).
4. Submucosal dissection. The anus is everted with eight
circumferential 4-0 silk sutures (Fig. 29.14). Identify the
dentate line and mark/score, (with diathermy tip), a circumference on the mucosa 5 mm more proximal (Fig. 29.15).
Beginning at the 12 o’clock position, the needle-tipped diathermy is used to incise the mucosa, and interrupted silk
sutures are placed from side to side in the mucosal layer and
tied. This seals the mucosal “tube” as the full circumference
of mucosa is developed (Fig. 29.16). The plane between the
submucosa and the white circular smooth muscle is developed inwards, with point diathermy controlling bleeding
points (Fig. 29.17). Firm but gentle traction is placed along
the ‘tube’ length. A point will be reached when the dissection begins to separate cleanly with minimal effort, requiring only cotton pledgets to tease the layers apart.
5. Breakthrough and prolapse. The mucosal tube is devel-
oped and the rolled circular muscle cuff is identified
(Fig. 29.18). The cuff is grasped posteriorly with two
Allis clamps. It is incised circumferentially, the bowel is
prolapsed, and the biopsy sites are noted as they come
through (Fig.
midline with scissors.
6. Anastomosis. The bowel is cut full thickness and an anastomosis is fashioned directly between the neorectum and
the circumference just proximal to the dentate line, using
absorbable interrupted sutures. Place the 3, 6, 9, and 12
o’clock positions first, leaving the sutures long as retractors clipped onto the drapes (Figs. 29.20 and 29.21).
Within each quadrant, three further absorbable sutures are
placed (Fig. 29.22). The everting stay sutures are then
removed, allowing the tissue to gently retract inwards
(Fig. 29.23).
7. Recheck. When the anastomosis is secured, the pulledthrough portion of bowel is viewed laparoscopically to
ensure that it is not twisted and it is lying without tension
(Fig. 29.24).
29.19). The cuff is split posteriorly in the
29 Laparoscopic-Assisted Soave Pullthrough for Hirschsprung Disease
217
a
b
c
Fig. 29.7 To take levelling biopsies, the wall of the colon is lifted with
fine-tipped forceps (Maryland) in the left hand (a), and scissors are used
to make a single bite (b) in this elevated portion. The tip of a V-shaped
tongue of colonic wall is lifted by the fine-tipped forceps in the left
hand, and the biopsy is developed on each side of the V using small
snips and spreading, undermining movements of the scissors. When
enough colonic wall has been dissected, cut across the base and send for
frozen section (c)
218
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Fig. 29.8 To achieve colonic mobilisation, the sigmoid colon is lifted
toward the anterior abdominal wall, using a grasper in the left hand
A.J. McCabe
Fig. 29.10 From the window, the mesenteric vessels are individually
diathermied with the hook, staying close to the colonic wall and working towards the pelvis
Fig. 29.9 A suitable mesenteric window is identified, and the hook
diathermy in the right hand is used to develop a small hole in the mesentery, through which the left-handed forceps can be placed (closed)
and lifted upwards to hold the colon
Fig. 29.11 When the peritoneal reflection is reached, a circumferential incision is made and the mesorectum is dissected as far down into
the pelvis as possible
29 Laparoscopic-Assisted Soave Pullthrough for Hirschsprung Disease
219
Fig. 29.12 The surgeon should check that the vascularised proximal
bowel to be pulled through reaches comfortably into the pelvis and
should make sure that both ureters are seen
Fig. 29.13 The patient is repositioned with the legs elevated over the
head
Fig. 29.14 Submucosal dissection begins with eversion of the anus
using eight circumferential 4-0 silk sutures
Fig. 29.15 After identifying the dentate line, the surgeon marks a circumference on the mucosa 5 mm more proximal
220
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A.J. McCabe
a
b
a
b
Fig. 29.16 (a, b) Using the needle-tipped diathermy, the mucosa is
incised and interrupted silk sutures are placed from side to side in the
mucosal layer and tied, to seal the mucosal tube
Fig. 29.17 (a, b) The plane between the submucosa and the white cir-
cular smooth muscle is developed inwards, with point diathermy controlling bleeding points
ab
29 Laparoscopic-Assisted Soave Pullthrough for Hirschsprung Disease
Fig. 29.18 (a, b) The
mucosal tube is developed
and the rolled circular muscle
cuff is identified
221
222
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A.J. McCabe
a
b
Fig. 29.20 An anastomosis is fashioned between the neorectum and
the circumference just proximal to the dentate line
Fig. 29.21 Absorbable interrupted sutures are first placed at 3, 6, 9,
and 12 o’clock. They are left long for retraction
Fig. 29.19 (a) The cuff is grasped posteriorly with two Allis clamps.
It is incised circumferentially, the bowel is prolapsed, and the biopsy
sites are noted as they come through (b)
Fig. 29.22 Three further absorbable sutures are placed in each
quadrant
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