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29 Laparoscopic-Assisted Soave Pullthrough for Hirschsprung Disease
223
Fig. 29.23 The stay sutures used for eversion of the anus are then
removed, allowing the tissue to gently retract inwards
Fig. 29.24 The pulled-through portion of bowel is viewed laparoscopically to ensure that it is not twisted and it is lying without tension
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A.J. McCabe
29.6 Highlights and Pitfalls
• An on-table washout may be necessary if the sigmoid
colon has not decompressed sufficiently (Fig. 29.25).
• Dissection for the initial 5-mm port must be kept perpendicular to the skin to aid precise dissection through the
layers of the body wall.
• If the level of ganglionated bowel is beyond the midtransverse colon, it is best to wait for permanent section biop-
a
sies, consider placing a distal ileal stoma, permanent section
biopsies of the more proximal colon, and consider placing
a distal stoma. Do remember to send ilieal biopsies too.
• If the biopsy causes mucosal breach, the defect is closed
with an absorbable suture.
• When the biopsies are sent, the gas and light source are
turned off. Care is taken to protect the patient’s skin from
the pressure effect of resting ports during submucosal dissection (Fig. 29.26).
b
Fig. 29.25 (a, b) An on-table washout may be necessary if the sig-
moid colon has not decompressed sufficiently
Fig. 29.26 The patient’s skin should be protected from the pressure
effect of resting ports during submucosal dissection
Laparoscopic-Assisted Swenson-Like
Transanal Pullthrough for Hirschsprung
Disease
Michael Stanton, Bala Eradi, and Marc A. Levitt
Abstract
Laparoscopic-assistance for Hirschsprung disease (HD) pullthrough procedures has
increased in popularity. This change has been associated in the UK, for example, with a
shift from the Duhamel procedure, which had been performed most frequently, to an
endorectal pull-through (ERPT) procedure that is being practiced more widely [1]. The
concept of the transanal only approach was put forth by Langer and de la Torre, but this was
using a Soave-like dissection, a problem noted by Swenson himself who originated this
concept with the original repair for HD [2]. The use of the Swenson-like technique for
ERPT has been popularized by Levitt and colleagues [3], who reported a series of 67
patients in 2013. The advantages of this approach are its simplicity, preservation of the
pelvic nerves, and avoidance of the obstructing muscle cuff that may occur after the SoaveBoley procedure [4]. The procedure can be undertaken as a purely transanal operation for
cases in which rectosigmoid aganglionosis is obvious from the contrast study, but initial
laparoscopic colonic mobilization and biopsy are preferred in most cases.
30
Keywords
Hirschsprung disease • Swenson-like pull-through • Laparoscopy
30.1 General Information
Laparoscopic-assistance for Hirschsprung disease (HD)
pullthrough procedures has increased in popularity. This
change has been associated in the UK, for example, with a
shift from the Duhamel procedure, which had been performed most frequently, to an endorectal pull-through
(ERPT) procedure that is being practiced more widely [
The concept of the transanal only approach was put forth by
Langer and de la Torre, but this was using a Soave-like dissection, a problem noted by Swenson himself who originated
M. Stanton (*)
Department of Paediatric Surgery,
Southampton Children’s Hospital, Southampton, UK
B. Eradi
Department of Paediatric Surgery,
Leicester Royal Infirmary, Leicester, UK
M.A. Levitt, MD
Nationwide Children’s Hospital,
The Ohio State University, Columbus, OH, USA
© Springer-Verlag Berlin Heidelberg 2017
M. McHoney et al. (eds.), Color Atlas of Pediatric Anatomy, Laparoscopy, and Thoracoscopy,
DOI 10.1007/978-3-662-53085-6_30
this concept with the original repair for HD [2]. The use of
the Swenson-like technique for ERPT has been popularized
by Levitt and colleagues [3], who reported a series of 67
patients in 2013. The advantages of this approach are its simplicity, preservation of the pelvic nerves, and avoidance of
the obstructing muscle cuff that may occur after the SoaveBoley procedure [4]. The procedure can be undertaken as a
purely transanal operation for cases in which rectosigmoid
1].
225
226
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M. Stanton et al.
aganglionosis is obvious from the contrast study, but initial
laparoscopic colonic mobilization and biopsy are preferred
in most cases.
30.2 Working Instruments
• 3-mm Ports and instruments: hook diathermy, graspers,
needle holders.
• 30° camera (5 or 3 mm)
• Lone Star retractor and needle-point (Lone Star Medical
Products, Houston, TX); hand-held monopolar diathermy
is used for the transanal approach.
30.3 Positioning, Port Siting
Ergonomic Considerations
and
For laparoscopic mobilization, the patient is positioned at
the foot of the table and turned 90°. This allows the operating surgeon to stand at the patient’s right shoulder facing
the pelvis, and the assistant can stand on the patient’s left
side. Full skin preparation of the lower limbs and abdomen
is undertaken, and the legs and feet are wrapped in crepe
bandage and bio-occlusive dressing sheets to allow repositioning intraoperatively. The laparoscopic stack is positioned at the feet end of the patient. Urethral catheterization
is required.
For the transanal approach, the prone position is preferable because this facilitates dissection between the rectum
and urethra in males (the rectum and vagina in females).
For laparoscopic dissection/biopsy and the transanal
approach, the patient can be positioned supine with the legs
elevated.
30.4 Relevant Anatomy
Dissection is done close to the rectal wall to avoid damage to
the pelvic nerves. If laparoscopic abdominal mobilization is
undertaken, both ureters (and vasa deferens in males) should
be identified and preserved.
30 Laparoscopic-Assisted Swenson-Like Transanal Pullthrough for Hirschsprung Disease
227
30.5 Surgical Technique
30.5.1 Laparoscopic Colonic Mobilization
Biopsy
and
The patient is initially positioned supine, as described above.
Three or four ports are used. In small infants it is helpful to
place these all above the umbilicus to allow more space for the
instruments. The camera port is placed high in the epigastrium, to the right of the midline (and falciform ligament). Two
lateral ports (3 mm) are placed. A fourth port placed in the left
upper quadrant can be helpful to grasp the sigmoid colon.
Insufflation pressure of 8–10 mmHg and a flow of 2–3 L/min
are used. The patient is positioned head-down so that the small
bowel can be displaced out of the pelvis. The rectosigmoid
colon is evaluated, and the likely transition zone is identified.
There are two options for confirmatory colonic biopsy with
frozen section histologic evaluation. A seromuscular colonic
biopsy can be taken from the taenia coli (Figs.
and 30.4) with a later full- thickness biopsy at the end of the
pull-through. The alternative is to take an initial full-thickness
colonic biopsy and suture the enterotomy closed (either laparoscopically or by exteriorizing the colon through one of the
port sites). This latter technique avoids the pitfall of ganglion
cells being noted in the muscular layer when there are hypertrophic nerves in the submucosal layer.
Colonic mobilization is started by elevating the sigmoid
colon by grasping the mesenteric edge of the bowel. Hook
monopolar diathermy is used to fashion a window in the
mesentery (Fig. 30.5). Further mesenteric division is continued proximally and distally (Fig. 30.6). Great care must be
taken to preserve the sigmoid mesenteric arcade and to ligate
the inferior mesenteric artery high near the aorta. This will
allow mobility of the colonic pull-through segment without
compromising its blood supply. The lateral colonic peritoneal attachments are displayed by drawing the colon medially and are again divided using hook diathermy (Fig. 30.6).
The left ureter should be identified at this stage. If need be,
the splenic flexure is taken down. Dissection is continued
(medially and laterally) distally to the peritoneal reflection
(Figs.
30.7 and 30.8), together with identification of the right
ureter. In males, the vas deferens should be identified at the
level of the peritoneal reflection. Mobilization of the rectum
beneath the peritoneal reflection should be to the deep pelvis,
making the transanal part required relatively minimal. For a
transition zone proximal to the mid-transverse colon, an
open approach is performed to carefully delineate the mesentery and to derotate the colon if necessary.
30.1, 30.2, 30.3,
30.5.1.1 Transanal Approach
If a transanal-only approach is used, the patient is positioned
prone, with the buttocks elevated. The Lone Star retractor
pins are placed initially at the anal mucocutaneous junction
(Fig.
30.9). The pins are then replaced deeper, so that the
dentate line is now buried and thus preserved (as is the distal
1.5 cm of the anal canal) (Fig. 30.10). The intended line of
stay sutures can be marked on the rectal mucosa if necessary
(Fig. 30.11). Interrupted stay sutures (e.g., silk) are placed in
the rectal mucosa 1 cm above the dentate line circumferentially. The sutures are placed on a single artery clip, which is
then used to provide uniform traction (Fig. 30.12).
A full-thickness rectal incision is made starting in the
posterior midline using needle-point monopolar diathermy.
Once the circumferential full-thickness Swenson plane is
established, the rectum is drawn outwards using traction on
the stay sutures (Fig. 30.13). Dissection is continued close to
the rectal wall with coagulation of extrinsic vessels in the
same fashion as employed in the posterior sagittal anorectoplasty. Dissection must be within the whitish fasciae that
envelops the rectum. The dissection is continued up to and
through the peritoneal reflection (Fig. 30.14). If a laparoscopic colonic mobilization was used, that plane of dissection is quickly reached. In such a case, supine with legs
elevated is appropriate and the rectosigmoid can be withdrawn easily (Fig.
the pull-through segment, and the antemesenteric border can
be marked with a suture (Fig. 30.16).
The coloanal anastomosis is fashioned in two layers using
absorbable sutures. The first layer is placed between the seromuscular layer of the pull-through colon and the proximal
(internal) incised rectal layer. The second layer sutures the
distal incised rectal tissue to the colon (mucosa to mucosa)
(Fig. 30.17). If the approach has been transanal only, a Hegar
dilator or large-bore tube is passed well into the pull-through
in the colon to ensure that there has been no twist.
The port site wounds are closed with absorbable sutures
under laparoscopic visualization and skin glue applied.
30.15). It is important to avoid twisting of
30.5.2 Highlights and Pitfalls
One of the key errors to avoid is inadvertent twisting of the
pull-through segment. Some surgeons advocate laparoscopy
to avoid this and passage of a Hegar dilator or large-bore
tube at the end of the procedure.
As for all HD cases irrespective of operative technique,
accurate intraoperative histologic confirmation of normal
ganglion cells and the absence of hypertrophic nerves
(defined as >40 μm) are essential. Some surgeons pause once
the initial laparoscopic biopsy is taken until confirmation of
the level is established; others continue but only complete
the coloanal anastomosis once a full-thickness specimen has
been evaluated. The pitfalls to avoid here are co-localized
ganglion cells in the intermuscular layer with hypertrophic
nerves in the submucosal plexus and spiral configuration of
the transition zone.
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Fig. 30.1 Laparoscopic colonic biopsies are taken for histologic
assessment, initially by grasping and elevating the taenia coli
M. Stanton et al.
Fig. 30.3 The biopsy instrument is grasped again and a seromuscular
or full-thickness biopsy is taken (see text)
Fig. 30.2 Dissecting scissors are used to cut the taenia coli
Fig. 30.4 The biopsy is withdrawn from the abdomen via one of the
ports under direct vision
30 Laparoscopic-Assisted Swenson-Like Transanal Pullthrough for Hirschsprung Disease
Fig. 30.7 Dissection continues to the peritoneal reflection, taking care
Fig. 30.5 A window in the sigmoid mesentery is made using monopo-
lar hook diathermy
to preserve the ureters and vasa
229
Fig. 30.6 The mesentery is divided proximally and distally staying
close to the bowel wall and using an electrocautery (or monopolar
hook) device
Fig. 30.8 The lateral colonic peritoneal attachment is divided to further mobilize the pull-through segment. The left ureter is identified and
preserved
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M. Stanton et al.
Fig. 30.9 Transanal approach: the Lone Star retractor in place, with
pins intitially at the dentate line
Fig. 30.11 A marking line is made 1–1.5 cm above the dentate line
Fig. 30.12 A circumferential row of sutures (e.g., 5/0 silk) is placed
cm above the dentate line
1.0
Fig. 30.10 The Lone Star pins are replaced sequentially so that the
dentate line is now hidden
30 Laparoscopic-Assisted Swenson-Like Transanal Pullthrough for Hirschsprung Disease
231
Fig. 30.13 Full-thickness dissection is started posteriorly and continues close to the rectal wall
Fig. 30.14 Dissection continues to the peritoneal reflection (clip
applied)
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M. Stanton et al.
Fig. 30.17 Laparoscopic view confirming the pull-through is not
twisted (note intact left ureter)
Fig. 30.15 The pull-through segment is now easily drawn down
Fig. 30.16 A two-layer coloanal anastomosis is completed
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