The Colorectal Quiz Episode 4: Classic Hirschsprung disease - Surgical Technique

Published: 2021-02-22

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Rod Gerardo — host
Jason Frischer — guest
Mark Levitt — guest
Aaron Garrison — guest
Andrea Badillo — guest
Speaker 6

Chapters

0:00Introduction and Case Recap — Podcast introduction, app promotion, and recap of two Hirschsprung cases from previous episode—one straightforward rectosigmoid and one proximal transition zone requiring different operative approaches.
2:31Preoperative Planning and Approach Selection — Discussion of patient readiness for OR, decision to use combined laparoscopic-transanal approach for rectosigmoid disease, rationale for laparoscopy to enable deep pelvic dissection and minimize transanal sphincter stretching.
5:40Laparoscopic Technique and Biopsy — Port placement strategy, full-thickness biopsy technique using anchor port at umbilicus, pathology requirements including ganglion cells and nerve size less than 40 microns with submucosa present, and mobilization of splenic flexure while awaiting frozen section.
10:40Mesenteric Dissection and Vascular Management — Mesenteric vessel division staying close to bowel wall to avoid nerve injury, preservation of left colic arcade, selective IMA division based on transition zone level, and emphasis on avoiding wide rectal dissection to prevent urinary and fecal incontinence.
13:51Transanal Dissection and Anastomosis — Patient positioning options, Lone Star retractor placement with dentate line identification, mucosal incision 1 cm above dentate line, Swenson full-thickness dissection in areolar plane versus Soave submucosal technique, pull-through with 5 cm margin above biopsy site, and anastomosis technique with seromuscular tacking sutures and mucosa-to-mucosa approximation.
18:20Closing and Preview — Summary of straightforward case technique, preview of next episode covering more complex proximal transition zone case, and promotion of Stay Current app colorectal channel.

Key claims

6:01Deep laparoscopic dissection into the pelvis minimizes transanal work and prevents overstretching of sphincters, a significant source of morbidity in Hirschsprung surgery — Mark Levitt
6:37Transanal dissection in primary pull-through should take well under 1 hour when preceded by adequate laparoscopic dissection — Jason Frischer
7:37Full-thickness biopsy should be cut as a cube with seromuscular side matching mucosal side dimensions — Mark Levitt
10:08Pathology must confirm ganglion cells present and nerves less than 40 microns in diameter — Andrea Badillo
10:20Biopsy specimen must include submucosa because ganglion cells may be present in seromuscular layer while hypertrophic nerves persist in submucosal layer — Mark Levitt
11:13Mesenteric dissection should stay as close to the bowel as possible without entering it, remaining in a less bloody plane — Aaron Garrison
11:52Too wide dissection of distal rectum in old Swenson technique caused urinary retention and incontinence, likely from injury to nervi erigentes — Mark Levitt
12:26For distal disease, only distal IMA branches need division; for left colon involvement, IMA itself may require division to achieve adequate reach — Jason Frischer
13:10Transanal mucosal incision should be made 1 centimeter above the dentate line — Andrea Badillo
13:24Lone Star retractor pins advance in three stages: starting at skin to identify dentate line, advancing to cover dentate line, then positioning at mucosal opening site — Andrea Badillo
14:12Swenson full-thickness dissection in the areolar plane is essentially bloodless — Mark Levitt
14:24If performing Soave technique with muscular cuff, the cuff should be very short (approximately 1 cm) and must be split — Mark Levitt
15:03Patient can remain supine with legs wrapped and fastened to ether screen for standard rectosigmoid cases; prone positioning reserved for more complex cases — Aaron Garrison
16:06Resection margin should be approximately 5 cm above the biopsy site where bowel appears healthy — Andrea Badillo
16:30Seromuscular tacking sutures to pelvic sidewall at 3 and 6 o'clock positions anchor the pull-through and facilitate mucosa-to-mucosa alignment — Aaron Garrison

Cases discussed

0:58One-day-old infant with rectosigmoid Hirschsprung disease presenting with abdominal distention and bilious emesis, confirmed by suction rectal biopsy

Points of disagreement

13:58Swenson versus Soave technique for pull-through
- Mark Levitt: Prefers Swenson full-thickness dissection in areolar plane; dislikes submucosal dissection and leaving a cuff
- Jason Frischer: Notes that Soave surgeons are making cuffs progressively shorter, and some have switched to Swenson technique

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Surgical Technique for Primary Pull-Through in Hirschsprung Disease

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Deep Laparoscopic Dissection Protects the Sphincter Complex

The most consequential technical decision in Hirschsprung pull-through is how much work you do laparoscopically versus transanally. Deep laparoscopic dissection into the pelvis minimizes transanal work and prevents overstretching of sphincters, a significant source of morbidity in Hirschsprung surgery 6:01. When preceded by adequate laparoscopic mobilization, transanal dissection in primary pull-through should take well under 1 hour 6:37. The corollary matters more than the time saved: if your transanal dissection is taking hours, you are stretching the sphincter complex in ways that will declare themselves years later as soiling or incontinence.

The Biopsy Must Include Submucosa

Full-thickness biopsy should be cut as a cube with seromuscular side matching mucosal side dimensions 7:37. The specimen must include submucosa because ganglion cells may be present in seromuscular layer while hypertrophic nerves persist in submucosal layer 10:20. Pathology must confirm ganglion cells present and nerves less than 40 microns in diameter 10:08. If your pathologist reports back that no submucosa was included, the biopsy is inadequate — you cannot exclude transition zone pathology without examining both layers.

Mesenteric Dissection Stays on the Bowel Wall

Mesenteric dissection should stay as close to the bowel as possible without entering it, remaining in a less bloody plane 11:13. This is not merely a hemostatic preference. Too wide dissection of distal rectum in old Swenson technique caused urinary retention and incontinence, likely from injury to nervi erigentes 11:52. The historical morbidity teaches the principle: work in the areolar plane immediately adjacent to bowel wall. For distal disease, only distal IMA branches need division; for left colon involvement, IMA itself may require division to achieve adequate reach 12:26.

Transanal Exposure Advances in Three Stages

Transanal mucosal incision should be made 1 centimeter above the dentate line 13:10. Lone Star retractor pins advance in three stages: starting at skin to identify dentate line, advancing to cover dentate line, then positioning at mucosal opening site 13:24. Each stage serves a purpose — the first orients you, the second protects the dentate line during initial dissection, the third maintains exposure without constant manual retraction that fatigues the sphincter.

Full-Thickness Dissection in the Areolar Plane

Swenson full-thickness dissection in the areolar plane is essentially bloodless 14:12. If you are encountering significant bleeding during the transanal dissection, you are in the wrong plane — either too superficial into muscle or too deep into perirectal fat. If performing Soave technique with muscular cuff, the cuff should be very short (approximately 1 cm) and must be split 14:24. The trend among experienced surgeons has been toward shorter cuffs or abandoning the cuff entirely, because a long unsplit cuff creates an obstructive segment.

Positioning and Resection Margin

Patient can remain supine with legs wrapped and fastened to ether screen for standard rectosigmoid cases; prone positioning reserved for more complex cases 15:03. Resection margin should be approximately 5 cm above the biopsy site where bowel appears healthy 16:06. There is no magic number, but 5 cm provides margin for error if the biopsy was taken close to transition zone.

Anastomotic Anchoring Prevents Retraction

Seromuscular tacking sutures to pelvic sidewall at 3 and 6 o'clock positions anchor the pull-through and facilitate mucosa-to-mucosa alignment 16:30. These are not a second layer in the traditional sense — they prevent the pull-through from retracting back into the pelvis before you complete the anastomosis. The emphasis on mucosa-to-mucosa edge alignment reflects accumulated experience: a well-aligned single-layer anastomosis heals better than a poorly aligned two-layer repair.

Takeaways from this story

Deep laparoscopic dissection protects sphincters by limiting transanal work to under 1 hour in primary cases
Biopsy must include submucosa to exclude hypertrophic nerves in submucosal layer despite ganglion cells in seromuscular layer
Mesenteric dissection stays on bowel wall to avoid nerve injury that historically caused incontinence and urinary retention
Swenson full-thickness dissection in areolar plane is bloodless; bleeding indicates wrong plane
If using Soave cuff, keep it very short (1 cm) and split it to avoid creating obstructive segment

Swenson versus Soave: The Evolving Debate on Pull-Through Technique in Hirschsprung Disease

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The Technical Question

Once the aganglionic segment is mobilized and the transanal dissection reaches the pelvis, the surgeon must choose between two fundamentally different approaches to the pull-through: full-thickness dissection in the areolar plane (Swenson) or submucosal dissection leaving a muscular cuff (Soave) 14:12 14:24. This is not a minor technical variation — it determines the tissue planes you work in, the structures you leave behind, and potentially the long-term functional outcome 14:12 14:24.

The Case for Full-Thickness Swenson Dissection

Mark Levitt states his position directly: "my preference is a Swenson full thickness, looking for the areolar plane. It's basically a bloodless plane. I don't like the submucosal dissection" 14:12. The technical advantage he emphasizes is the plane itself — when you find the correct areolar layer around the rectum, the dissection proceeds with minimal bleeding 14:12. More fundamentally, he objects to leaving any muscular cuff behind 14:12. The Soave technique, by definition, leaves a segment of aganglionic muscle on the pelvic floor, and Levitt's position is that this tissue should not remain 14:12.

The historical context matters here. Levitt notes that the original Swenson technique, performed entirely through the abdomen with wide pelvic dissection, caused urinary retention and incontinence, likely from injury to the nervi erigentes 11:52. The modern transanal Swenson avoids this by staying immediately on the bowel wall, but it preserves the full-thickness principle — you take all layers of the diseased rectum and leave nothing behind 11:52 14:12.

The Soave Position and Its Evolution

Jason Frischer does not advocate for the traditional Soave technique in this discussion, but he describes its trajectory: the Soave surgeons have been progressively shortening the muscular cuff over time 14:24. What began as a long muscular sleeve has contracted as surgeons recognized that the cuff itself could be problematic 14:24. Levitt acknowledges this evolution, noting that some Soave surgeons now create cuffs of only 1 centimeter, and that at least one prominent surgeon has abandoned the technique entirely and switched to Swenson 14:24.

The critical technical point, if a cuff is made at all, is that it must be very short — approximately 1 cm — and must be split 14:24. An unsplit cuff can cause obstruction 14:24. A long cuff leaves more aganglionic muscle in place 14:24. The progressive shortening of the cuff suggests that Soave surgeons themselves have recognized these problems and are moving toward a technique that increasingly resembles full-thickness dissection 14:24.

Where They Agree

Both approaches depend absolutely on adequate laparoscopic mobilization before any transanal work begins 6:01 6:37. Levitt emphasizes that deep laparoscopic dissection into the pelvis minimizes transanal work and prevents overstretching of the sphincters, which is a significant source of morbidity 6:01. Frischer reinforces this: when the laparoscopic dissection is adequate, the transanal portion should take well under 1 hour in a primary pull-through 6:37. This is not a Swenson-versus-Soave issue — it is a prerequisite for either technique 6:01 6:37.

Both also agree on staying immediately on the bowel during mesenteric and rectal dissection 11:13 11:52. Aaron Garrison describes staying close to the bowel wall in a relatively avascular plane 11:13. Levitt emphasizes this point explicitly, noting that the old abdominal Swenson caused morbidity because the dissection was too wide 11:52. The modern principle — whether you are doing Swenson or Soave — is to stay on the bowel wall and avoid injury to pelvic autonomic nerves 11:13 11:52.

What Would Resolve It

The discussants do not propose a trial or specify what evidence would settle the question. What the discussion reveals instead is a convergence: Soave surgeons are making shorter cuffs, splitting them, and in some cases abandoning the technique entirely 14:24. Levitt's position is that if you are going to make a cuff at all, it should be very short and split, but his clear preference is not to make one 14:12 14:24. The trajectory suggests that the distinction may be collapsing — that what some surgeons call a very short split Soave is functionally approaching a Swenson, and that the remaining question is whether any cuff, however short, offers an advantage that justifies leaving aganglionic muscle behind 14:12 14:24.

The debate is not resolved, but it is narrowing 14:24. The technical principles both sides now follow — deep laparoscopic mobilization, minimal transanal dissection, staying on the bowel wall, and if a cuff is made, keeping it very short and splitting it — suggest that the functional outcomes may be converging as well 6:01 6:37 11:13 11:52 14:12 14:24.

Takeaways from this story

Swenson full-thickness dissection in the areolar plane is essentially bloodless when the correct plane is identified
If performing Soave, the muscular cuff must be very short (≈1 cm) and must be split to avoid obstruction
Deep laparoscopic pelvic dissection minimizes transanal work and prevents sphincter overstretching regardless of technique
Modern technique requires staying immediately on the bowel wall to avoid pelvic nerve injury seen with older wide dissections

Combined Laparoscopic-Transanal Pull-Through for Hirschsprung Disease: Technique and Rationale

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why This Approach Exists

Hirschsprung disease requires resection of aganglionic bowel and anastomosis of healthy proximal colon to the anus 6:01. Historically, this was done entirely through the abdomen (Swenson) or entirely transanally, both approaches carrying significant morbidity 11:52. The combined laparoscopic-transanal technique emerged to solve a specific problem: how to achieve adequate pelvic dissection without overstretching the anal sphincters, which causes injury 6:01. The old purely transanal approach could take hours; the modern hybrid technique reduces transanal work to under an hour 6:37.

The Core Problem

The surgeon must remove all aganglionic bowel while preserving sphincter function and pelvic autonomic nerves 6:01. This requires working in a narrow pelvis through a small anus in an infant 6:37. Too much transanal dissection stretches and injures the sphincter complex 6:01. Too wide a pelvic dissection injures the nervi erigentes, causing urinary retention and fecal incontinence — complications seen with the original abdominal Swenson technique 11:52. The combined approach divides the work: laparoscopy handles the deep pelvic dissection where visualization is better, leaving only the final centimeters for transanal work 6:01 6:37.

Laparoscopic Phase

Port placement uses an anchor port at the umbilicus, which provides an 8mm fascial opening — enough room to perform the critical intraoperative biopsy 7:37. The biopsy is cut as a cube with equal seromuscular and mucosal dimensions, and pathology must confirm two things before proceeding: ganglion cells present and nerve diameter less than 40 microns 10:08. Crucially, the specimen must include submucosa, because ganglion cells may appear in the seromuscular layer while hypertrophic nerves persist in the submucosal layer 10:20. While awaiting frozen section, the surgeon mobilizes the splenic flexure and takes down the retroperitoneal attachments 7:37.

Mesenteric dissection follows a strict plane: staying close to the bowel wall to avoid injury to autonomic nerves in the mesentery and to remain in a less bloody plane 11:13. For distal rectosigmoid disease, only the distal branches of the inferior mesenteric artery require division; when the transition zone extends into the left colon, the IMA itself may need to be taken to achieve adequate reach 12:26. The key is preserving the left colic arcade to maintain perfusion 12:26.

The laparoscopic dissection continues deep into the pelvis, again staying immediately on the rectal wall 11:13. This is where the old abdominal Swenson went wrong: too wide a dissection of the distal rectum injured pelvic autonomic nerves, causing the incontinence and urinary retention that gave the operation a bad reputation 11:52.

Transanal Phase

For standard rectosigmoid cases, the patient can remain supine with legs wrapped and fastened to the ether screen; prone positioning is reserved for more complex proximal disease 15:03. The Lone Star retractor is placed in three stages: pins start at the skin to identify the dentate line, advance to cover it, then position at the site of mucosal opening 13:24. The mucosal incision is made 1cm above the dentate line 13:10.

Two dissection techniques are available 14:12 14:24. The Swenson full-thickness dissection proceeds in the areolar plane and is essentially bloodless 14:12. The Soave technique creates a submucosal plane, leaving a muscular cuff — but if this approach is used, the cuff must be very short (approximately 1cm) and must be split posteriorly 14:24. Many surgeons have abandoned the cuff entirely, and some who historically preferred Soave have switched to full-thickness dissection 14:12 14:24.

Once the bowel is delivered, the surgeon identifies the biopsy site and resects approximately 5cm proximal to it, where the bowel appears healthy 16:06. The anastomosis begins with seromuscular tacking sutures to the pelvic sidewall at 3 and 6 o'clock, which anchor the pull-through and facilitate mucosa-to-mucosa alignment 16:30. The emphasis is on precise mucosal edge approximation rather than relying on full-thickness bites alone 16:30.

What Remains Contested

The choice between Swenson and Soave technique persists, though the trend is toward full-thickness dissection or very short split cuffs 14:12 14:24. The role of laparoscopy itself is not contested among these surgeons, but they acknowledge that surgeons without laparoscopic access can achieve good results using alternative approaches 7:37.

When to Involve This Team

Any neonate with delayed passage of meconium beyond the first day or two of life, abdominal distension, or bilious emesis requires rectal biopsy to rule out Hirschsprung disease 6:01. Once the diagnosis is confirmed, referral to a pediatric colorectal surgeon is appropriate 6:01. The discussion here assumes a stable infant ready for primary pull-through; unstable neonates or those with enterocolitis may require initial diverting colostomy 6:01. The technical points discussed — biopsy adequacy, mesenteric dissection plane, sphincter protection — are relevant primarily to the operating surgeon, but the referring clinician should understand that modern outcomes depend heavily on minimizing sphincter trauma, which is why transanal dissection time has become a quality metric 6:01 6:37.

Takeaways from this story

Deep laparoscopic pelvic dissection reduces transanal work to under 1 hour, minimizing sphincter stretch injury
Intraoperative biopsy must include submucosa and confirm both ganglion cells and nerve diameter <40 microns
Mesenteric dissection tight to bowel wall avoids autonomic nerve injury that caused incontinence in older techniques
Mucosal incision 1cm above dentate line with staged Lone Star pin advancement protects sphincter complex
If using Soave technique, muscular cuff must be very short (≈1cm) and split to avoid obstruction

Topic overview

Expert panel discussion on laparoscopic-assisted transanal pull-through technique for classic rectosigmoid Hirschsprung disease. The discussants detail port placement, full-thickness biopsy technique requiring ganglion cells and nerves less than 40 microns, mesenteric dissection staying close to the bowel wall to avoid nerve injury, and transanal dissection beginning 1 cm above the dentate line. Key technical points include deep laparoscopic pelvic dissection to minimize transanal sphincter stretching, Swenson full-thickness dissection in the areolar plane, and mucosa-to-mucosa anastomosis with seromuscular tacking sutures.

Key takeaways

Deep laparoscopic pelvic dissection minimizes transanal sphincter stretching, reducing major morbidity in Hirschsprung surgery. (6:01)
Full-thickness biopsy must include submucosa; ganglion cells may be present seromuscularly while hypertrophic nerves persist submucosally. (10:08)
Stay close to bowel wall during mesenteric dissection; wide dissection risks nerve injury causing urinary retention and incontinence. (11:13)
Swenson full-thickness dissection in the areolar plane is essentially bloodless when performed correctly. (14:12)
Begin transanal mucosal incision 1 cm above dentate line; seromuscular tacking sutures at 3 and 6 o'clock anchor pull-through. (13:10)

Keywords

Hirschsprung disease abdominal distention bilious emesis urinary retention incontinence appendicitis laparoscopic-assisted transanal pull-through Swenson technique Soave technique suction rectal biopsy full-thickness biopsy frozen section splenic flexure mobilization circumcision Cincinnati Children's

Hashtags

#HirschsprungDisease #PediatricSurgery #ColorectalSurgery #LaparoscopicSurgery

Transcript

Click "Show Transcript" to view the full text (17370 characters)

Hey there listeners. We've got a brand new version of the Stay current app, brand new layout, new content, new features. But one of our favorite new features is something that we call channels. So, think of your favorite streaming service. You know how they organize content by genre? Well, we're doing that with pediatric surgery. So if you love this podcast, You can go to our colorectal channel, scroll through podcasts and videos that have to do with colorectal surgery, or maybe you'd love iPE's content. They got a channel too. So download the Stay Current in pediatric surgery app. It's in the Apple App Store, it's in the Google Play store. But until then, Enjoy the episode Last week on the colorectal quiz. So, the next case is a one day old and presents with significant abdominal distention and bio emesis. So, I think we've discussed our basic workup and resuscitation, and now, we get a plain abdominal X-ray, and this is what we see. There's definitely It's not your standard Hirschprung's picture. Um, so, a head scratcher for Todd, do you think it was for Doctor Levitt too? A little bit more complicated than the first case. Yeah, it's not so obvious. Uh, so, to finish this case, rectal biopsy, suction rectal biopsy confirms the diagnosis of Hirschberg's disease, but I think this leads us to the next conversation. These two patients probably will have different operative approaches. Two different operative approaches for the same disease, because one is more proximal and more complicated, and the other is more distal. So, be honest, did we leave you on the edge of your seat for a whole week? Well, Worry no further, because we're going to get into that this week. We're gonna talk about the operative technique for Hirschsprung disease. I'm Rod Gerardo from Cincinnati Children's, and this is the colorectal quiz. Rod, you are to colorectal surgery as Michael Barbaro is to the New York Times and The Daily. So, thank you for all your efforts. That's flattering. I appreciate it. Thank you. That's Doctor Mark Levitt at Children's National Hospital in Washington DC really just pouring on the compliments, but I appreciate it because I'm trying to do what the daily does. Tell a story. I'm just trying to do it with colorectal surgery. Now that we all know each other, you know, Jason, you know, remember, Aaron Garrison could barely tie his shoes. Here we go. Doctor Levitt and Doctor Fisher at Cincinnati Children's are talking about their former fellow, Doctor Aaron Garrison, who was also on the call. We thought it might turn into a 3-year fellowship, but he, uh, he was able to skate out in 2. Once a fellow, always a fellow, that's the truth, especially if you guys. And we were lucky enough to be joined by another expert in pediatric colorectal surgery, Andrew Badillo, my partner in crime and colorectal surgery here in Washington DC. So for those of you who haven't been following along every week, Doctor Levitt and Doctor Frischer gave us two different Hirschprung patients. One was the more straightforward transition zone in the rectosigmoid, and then the other was a little bit more complicated, a baby with bilious emesis, and then the workup revealed a proximal transition zone. Yeah, so, we really wanna focus this week on the um surgery. If you're listening to this on the Stay Current app, scroll down a little bit under the media player, you can look at the X-ray and the contrast enema for the patient that Doctor Levitt and Doctor Frischer are talking about. You know, Mark, I think the two of us talking, have you ever seen The Muppet Show, and there's two old guys in the balcony? Doctor Badillo and Doctor Garrison agreed that Those two Muppets were basically what Dr. Levin and Dr. Fisher are like, so. I got another bonus picture there for you. Aaron, kick us off. The baby's well, irrigations are going well. The baby's in the NICU, um, smiling at you, belly's flat. Biopsy showed Hirschberg's, we discussed. Should we go to the OR? Yeah, I think definitely ready for the OR, um, uh, you know, a patient who's in our NICU, we wouldn't necessarily bowel prep. We would probably, especially if they're, um, breastfed. So we would keep irrigations going though until uh we've got OR time. We have some antibiotics and some blood available just for, to be safe, although we typically, obviously, don't need that for this operation. And then we'd go to the OR and uh decide about our approach. Uh, with this contrast study, I think my favorite approach is to combine through laparoscopy and, and transanally. So I would do a full body prep and start the procedure, uh, from the abdomen. And Doctor Badillo agreed. Oh no, I mean, I, I like Aaron's approach. Uh, I like laparoscopy. I don't like to have surprises and if there's a, if it's not a rectal sigmoid transition, then you have the ability to biopsy elsewhere pretty easily. But what's the most important reason to consider laparoscopic? Probably the most important thing I think though, is a good deep Uh, laparoscopic dissection into the pelvis so that you have very minimal transatal work to do. I think unfortunately, you know, Jason and I and you and uh Aaron and Andrea see a lot of the morbidity associated with Hirschberg's disease and the overstretching of the sphincters which can be done if you do an extensive transanal amount of work. It's really a morbidity that, that needs to be avoided, and laparoscopy helps with that. And Doctor Frischer is even more strict about the stretching. Previously, we used to do this transanally, it would take a few hours. Now, the transanal dissection should be usually way under 1 hour, especially in a primary pull-through point. I just, for completion's sake, there are surgeons out there, we're talking to the whole world here that don't have laparoscopy available to them. Jack Langer has showed us a very nice Uh, sort of umbilical approach. You can do an incredible amount of work in an umbilical approach, so I wanna keep that option in mind. Doctor Garrison tried to keep us on track. Can we talk about basics for a second though about like actually obtaining the biopsy, cause I think there's some, personally, I like using an anchor port, which I hate to give more credit to Todd, but he introduced to me. The anchor port gives you like, um, it's got a low profile, so there's not a lot of um instrumentation in the abdomen. It also has about an 8 millimeter fascial incision, so it gives you just a little bit more room to work and do the biopsy kind of at the umbilicus. So important to do a full thickness biopsy, and I like to cut a square, like a cube. And if we're looking at the sides of that cube, you wanna make sure that the seromuscular side is the same as the mucosal side. And then of course, you can suture it up extra corporeally, make sure that it's labeled appropriately for pathology, because, as you know, that has implications on where you make your pull through. Andrea, do you wanna give us some insight on how you set up, if you're doing this laparoscopically, how you set up your ports? So, obviously, um umbilical port and then um Right lower quadrant and upper quadrant ports on the right side and then switch the camera off into that right upper quadrant port and then use the uh umbilical port in the right lower quadrant as your working ports. And if you need another port, cause the sigmoid is very floppy, where do you put that? Um, that it kind of depends right over the sigmoid, really, but that, that one's variable. I, I definitely like using that extra little stab incision assistant port on the left side. You can make the dissection for the fellows a little easier. You can expose a little bit better, so I, I agree. Its scinating. It's fascinating that you would bring that up because when you were the fellow, boy, did we have to fall over ourselves to try to make you look good. I know I have that vivid memories of all of that. OK guys, let's get back to the matter at hand. So, we have a rectosigmoid transition zone, we took our full thickness biopsy through our laparoscopic approach. Now what? Do you take the mesentery? How do you take the mesentery, and how far or low do you go? I still would wait for your frozen section before I start taking mesentery, and so, I mean, mobilizing this plenic flexure, making sure that what you uh are hoping comes. Back is uh uh good news on the frozen section will reach, but I usually don't start taking mesentery until I, I know for sure. So, we're mobilizing, we're making sure we don't have too much tension when we finally bring our two pieces together. And we're waiting for pathology. What are the absolute things that we need to hear from our pathologists? So that we're good to go. Absolutely. So ganglion cells, but then nerves that are less than 40 microns. So we, we don't wanna pull through a segment with hypertrophied nerves. Yes, and I would also add, they must see submucosa, and if you send them a biopsy without submucosa, our pathologist will say, hey, where's the submucosa? Because you want to make sure again that you don't find ganglion cells in the serum muscular layer and hypertrophic nerves in the submucosal layer. All right. So let's say the biopsy comes back, and just like Doctor Padilla says, we're good to go, then what? All right, Aaron, now, what is, what are your moves? You said you took down the splenic flexure if you need to. You took the retroperitoneal attachments to the left colon. What are you doing actually for the mesenteric? Um, well, at that point, then, you know, we're proceeding with our pull-through, and there's a, a variety of options. We've been using the just right sealer a little more to dissect and take some of those, um, mesenteric vessels. The hook works nicely as well. We try staying just off the, off the bowel, so not really getting down into the deep portion of the mesentery, but as close to the bowel as you can without getting into it. And it tends to be um a little less bloody in that, in that plane. And so, um, you know, we would just start somewhere where, where it's easy and make a, make a hole in the mesentery, dissecting through it and then cauterizing up and down all the way into the pelvis and both, both leaves of the mesentery. You know, I wanna, I wanna emphasize something, Aaron, you're a very technically elegant surgeon. I've always thought that. You're making a very important point. You need to be right on the bow, because in the old days, the old Swenson. Done through the abdomen. Patients were um incontinent, non-infrequently, and they had urinary retention non-frequently. And I believe that it was related to a too wide of a dissection of the distal rectum and an injury to the nerve erigentis. So, when you're doing this dissection, what should you consider when it comes to the arterial supply? How do you decide which vessels you need to take? You need to be very careful of preserving the arcade along the left colon and sigmoid colon, so you could get enough distance to reach the pelvis. Doctor Frischer then explains that if it's distal disease, like what we're talking about here, you could just be taking distal branches of the IMA, but, When you're dealing more with your left colon, you might have to take the IMA to get the left colon or splenic flexure to reach. All right, so let's move on to the transanal part of the procedure. Scroll down, click on the next image, you're gonna see the transanal exposure with the Lone Star retractors. And here's Doctor Badeo. So I, I think of this part is do, do no harm to the dentate line nor to the sphincters. I like to identify the, the dentate line. And then make a mark about 1 centimeter above that into the anal canal and that's gonna be the, the line that we're gonna divide along to start the dissection. And the pins will start at the skin, these three positions you were talking about, so you can help identify that dentate line. Then they're gonna advance to cover the dentate line. And then the third maneuver is at your, um, where you open the mucosa and start your dissection. They'll bring that all underneath the pins and then you'll continue your dissection um superiorly. That that 3rd move is extremely helpful. And now we talk about the pull through. And we've got options. The Suave technique or the Swenson technique, or what I see a lot of people doing what I would call, to quote Dan von Almen, the Swanson technique. Do you do a full thickness dissection or do a submucosal dissection? My preference is a Swenson full thickness, looking for the areolar plane. It's basically a bloodless plane. I don't like the submucosal dissection. Because I don't want to leave a cuff, um, but the suave is out there have been making that cuff shorter and shorter and shorter. Jack Langer will do about a 1 centimeter cuff now, and Luis told me that he's now doing a Swenson. Um, so if you're gonna do a cuff cause you feel compelled to do it, make it very, very short, and that's something we might call a, a swanson. And you split the cuff. Yeah, you must split, split the cuff. Again, Doctor Garrison was quick to point out that we might have forgotten something. Yeah, I don't think we, uh, clarified whether you turn the baby prone again or whether you do the operation. Great point. Personally, in this kind of standard sort of patient, I, I like keeping the patient supine, having the legs wrapped with the full body prep and, and fastening. The legs with the uh clamp to the, what's that bar, the anesthesia bar, the ether screen, the ether screen, right. And so, you know, I put a little sterile bump under them and do it that way, and that way there's less flipping, although, you know, for more complex cases, being able to do it prone, I think is advantageous. And it, it gives an opportunity for everybody to get involved, the anesthesia. Theologist can hold the clamp. Well, sometimes you got to wake them up. All right, let's get back. So now that Aaron brought us and properly positioned the patient, even though we were in our, in our supine patient, in our supine patient, you're in the Swenson plane, and if you've done a lot of really good work, uh, laparoscopically, then that dissection shouldn't take you too long, and you're going to meet your dissection from above and maybe get a gush of fluid or something, and you know that you've gotten into that peritoneal space. So you're, you're bringing that bowel through. You'll find your biopsy site. I like to go above that. How far above do you like to go? Uh, no, no magic number. I think you can really see that the bowel looks good, um, and that's probably influenced where you did your biopsy to begin with, and then to give yourself a 5 centimeter margin or so above that is very safe, I think. OK, so we did our pull through. We have a safe landing zone. Let's talk about the anastomosis. Um, I do like putting two kind of tacking sutures on the, on the serosa to the side wall, so I don't think it technically counts as like a two-layer anastomosis, but I think it just kind of anchors it in place laterally through the pelvic side wall in the kind of 3 and 6 o'clock positions. Open up the anterior half of the anastomosis and anchoring sutures there, and I, I usually use 40 micro pops for these set up kind of 12, 3, and 6 o'clock and put the, the in-betweeners before transsecting the, the rest of the uh bowel. All four of the surgeons on the call agreed that the reinforcement layer that Doctor G Garrison talked about is critical to lining the two pieces of bowel up. So that you have mucosa edge to mucosa edge, which is really the key part of it. We ran out of time, but even though they were joking throughout the whole podcast, They still had time for one more. So guys, there was um there were these two kids in the holding area about to go into the surgery, and they recognized each other. They were from the same class. They're both 11 years old. And the one kid said to the other, hey, um, what, what do you, are you having surgery? What are you having surgery for? And he said, well, they tell me that it's my appendix. I have appendicitis. And the kid said, oh, don't worry about that. I had that, and I bet you're gonna be going home tomorrow. You're, you're fine, and I'll see you back in school. What about you? What are you having done? The kid said, I'm having a circumcision. And the kid who was having the appendicitis said, Oh my God. Are you serious? I had that when I was a baby, and I could not walk for a year. That's a good one. Mark, much improvement. Nice work. Good good delivery too, good delivery. There you have it, the surgical technique from 4 expert pediatric colorectal surgeons. But that was the straightforward case. Next week We're gonna talk you through the more complicated case that we presented a couple of weeks ago. And while you're waiting, Go ahead and check out the colorectal channel on the Stay Current app. Or maybe you've seen all that. Follow us on social media. We're on Instagram, Facebook, Twitter. Don't take my word for it. Here's Doctor Garrison. I'm just hoping to make it into one of Rod's TikToks one day. That's when I'll know I've arrived. Don't worry, Doctor Garrison, I'll get you on TikTok soon enough. But until next time, I'm Rod from Cincinnati Children's, and remember, knowledge should be free.

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