The Colorectal Quiz Episode 4
With Dr. Mark Levitt & Dr. Andrea Frischer & Dr. Andrew Badillo & Dr. Aaron Garrison · hosted by Dr. Rod Girardo · Marc Levitt
Cued at 16:30 · stops at 17:15 · press play
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
Suction rectal biopsy confirms the diagnosis of Hirschsprung's disease
Two different operative approaches exist for Hirschsprung disease depending on whether transition zone is proximal and complicated versus distal
For non-rectosigmoid transition zones, combined laparoscopy and transanal approach is preferred
Deep laparoscopic dissection into pelvis minimizes transanal work needed
Overstretching of sphincters during extensive transanal dissection is a morbidity that needs to be avoided
Transanal dissection should take under one hour in a primary pull-through
Full thickness biopsy must include seromuscular side same size as mucosal side, cut as a square cube
Port placement includes umbilical port, right lower and upper quadrant ports, with camera switched to right upper quadrant
Should wait for frozen section before taking mesentery
Pathology must confirm ganglion cells and nerves less than 40 microns
Biopsy must include submucosa to avoid finding ganglion cells in seromuscular layer but hypertrophic nerves in submucosal layer
Mesenteric dissection should stay close to bowel wall, not deep in mesentery, to reduce bleeding
Must stay right on the bowel during dissection because too wide dissection of distal rectum causes incontinence and urinary retention from nerve injury
Must preserve arcade along left colon and sigmoid to get enough distance to reach pelvis
For distal disease, can take just distal branches of IMA; for left colon involvement may need to take IMA to get reach
Transanal dissection should identify dentate line and mark about one centimeter above into anal canal for division line
Preference is Swenson full thickness dissection in areolar plane which is bloodless, not submucosal dissection with cuff
If doing a cuff, make it very short (about one centimeter) and must split the cuff
Patient can be kept supine with legs wrapped and fastened to ether screen for standard cases
Should go about five centimeters above biopsy site for safe margin
Tacking sutures on serosa to sidewall at three and six o'clock positions anchor bowel in place
Reinforcement layer is critical to line up mucosa edge to mucosa edge