The Colorectal Quiz Episode 4

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 Girardo — host
Speaker 2 — host
Mark Levitt — guest
Andrea Frischer — guest
Andrew Badillo — guest
Aaron Garrison — guest

Chapters

0:00Case Presentation and Introduction — Introduction of a one-day-old with abdominal distension and bilious emesis, confirmed Hirschsprung disease by rectal biopsy. Discussion of two different operative approaches based on transition zone location.
2:26Preoperative Planning and Laparoscopic Approach — Panel introductions and discussion of preoperative preparation, decision for combined laparoscopic and transanal approach for non-rectosigmoid transition zones.
5:40Laparoscopic Technique and Biopsy — Port placement, full-thickness biopsy technique, and pathology requirements including ganglion cells, nerve size, and submucosa visualization.
10:48Mesenteric Dissection and Transanal Exposure — Mesenteric vessel management staying close to bowel wall, splenic flexure mobilization, and transanal exposure technique protecting the dentate line.
13:54Pull-Through and Anastomosis — Swenson versus Soave technique discussion, full-thickness dissection in areolar plane, and anastomotic technique with reinforcement sutures.
17:19Closing and Preview — Wrap-up with preview of next episode covering more complicated proximal transition zone case.

Key claims

1:37Suction rectal biopsy confirms the diagnosis of Hirschsprung's disease — Speaker 2
1:37Two different operative approaches exist for Hirschsprung disease depending on whether transition zone is proximal and complicated versus distal — Speaker 2
5:03For non-rectosigmoid transition zones, combined laparoscopy and transanal approach is preferred — Andrea Frischer
5:56Deep laparoscopic dissection into pelvis minimizes transanal work needed — Andrew Badillo
5:56Overstretching of sphincters during extensive transanal dissection is a morbidity that needs to be avoided — Andrew Badillo
6:33Transanal dissection should take under one hour in a primary pull-through — Mark Levitt
7:09Full thickness biopsy must include seromuscular side same size as mucosal side, cut as a square cube — Aaron Garrison
8:16Port placement includes umbilical port, right lower and upper quadrant ports, with camera switched to right upper quadrant — Mark Levitt
9:30Should wait for frozen section before taking mesentery — Andrew Badillo
10:00Pathology must confirm ganglion cells and nerves less than 40 microns — Andrew Badillo
10:19Biopsy must include submucosa to avoid finding ganglion cells in seromuscular layer but hypertrophic nerves in submucosal layer — Andrea Frischer
11:00Mesenteric dissection should stay close to bowel wall, not deep in mesentery, to reduce bleeding — Andrea Frischer
11:42Must stay right on the bowel during dissection because too wide dissection of distal rectum causes incontinence and urinary retention from nerve injury — Mark Levitt
12:26Must preserve arcade along left colon and sigmoid to get enough distance to reach pelvis — Andrea Frischer
12:35For distal disease, can take just distal branches of IMA; for left colon involvement may need to take IMA to get reach — Mark Levitt
13:02Transanal dissection should identify dentate line and mark about one centimeter above into anal canal for division line — Andrew Badillo
14:12Preference is Swenson full thickness dissection in areolar plane which is bloodless, not submucosal dissection with cuff — Mark Levitt
14:12If doing a cuff, make it very short (about one centimeter) and must split the cuff — Mark Levitt
15:04Patient can be kept supine with legs wrapped and fastened to ether screen for standard cases — Andrea Frischer
16:06Should go about five centimeters above biopsy site for safe margin — Andrea Frischer
16:30Tacking sutures on serosa to sidewall at three and six o'clock positions anchor bowel in place — Aaron Garrison
17:00Reinforcement layer is critical to line up mucosa edge to mucosa edge — Rod Girardo

Cases discussed

0:53One-day-old with Hirschsprung disease, rectosigmoid transition zone

Points of disagreement

14:12Swenson versus Soave technique for pull-through
- Mark Levitt: Prefers Swenson full-thickness dissection in areolar plane, avoiding submucosal dissection and cuff
- Mark Levitt: Notes that Soave surgeons are making cuffs shorter, and if doing cuff must make it very short (one centimeter) and split it

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:

Proximal Hirschsprung Disease: When Laparoscopy Protects the Sphincters

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Case narrative · AI-written, human-reviewed

Presentation

A one-day-old presented with significant abdominal distension and bilious emesis 1:37. Plain abdominal radiography was obtained, though the discussants noted the findings were "not your standard Hirschsprung's picture" — the transition zone was proximal, not the typical rectosigmoid location. Suction rectal biopsy confirmed Hirschsprung disease 1:37.

The Decision Point

The proximal transition zone forced a choice between operative approaches 1:37. A purely transanal pull-through, while feasible for distal disease, would require hours of dissection through the anal canal to reach a proximal transition zone. That prolonged transanal work carries a specific morbidity: overstretching of the sphincters, which the discussants identified as a preventable cause of long-term incontinence 5:56. The alternative — combined laparoscopic and transanal approach — shifts most of the dissection to the abdomen, where visualization is better and the sphincters are not at risk 5:03.

The team chose the combined approach. As one discussant put it, "a good deep laparoscopic dissection into the pelvis so that you have very minimal transanal work to do" is the key to avoiding sphincter injury 5:56. In a primary pull-through, transanal dissection should take under one hour 6:33.

What They Did

Port placement was umbilical, right lower quadrant, and right upper quadrant, with the camera moved to the right upper quadrant for working access 8:16. The team mobilized the splenic flexure and took down retroperitoneal attachments, then performed a full-thickness biopsy. The biopsy technique matters: it must be cut as a square cube, with the seromuscular side the same size as the mucosal side, and must include submucosa 10:19. One discussant explained that you want to make sure you don't find ganglion cells in the seromuscular layer and hypertrophic nerves in the submucosal layer 10:19.

They waited for frozen section before taking mesentery 9:30. Pathology had to confirm two things: ganglion cells present, and nerves less than 40 microns 10:00. Only then did they proceed with mesenteric dissection.

The mesenteric dissection stayed close to the bowel wall, not deep in the mesentery, to reduce bleeding 11:00. This plane also matters for another reason: "You need to be right on the bowel. Because in the old days, the old Swenson done through the abdomen, patients were 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 arogenic case" [q2]. The arcade along the left colon and sigmoid had to be preserved to achieve adequate reach into the pelvis 12:26. For this rectosigmoid disease, only distal branches of the inferior mesenteric artery needed to be taken; more proximal disease might require taking the IMA itself to get the colon to reach 12:35.

The patient remained supine with legs wrapped and fastened to the ether screen 15:04. Transanal dissection began one centimeter above the dentate line 13:02. One discussant framed the goal simply: "do no harm to the dentate line nor to the sphincters" [q3]. The team performed a Swenson full-thickness dissection in the areolar plane, which is essentially bloodless, rather than a submucosal dissection with a cuff 14:12. If a cuff is used, it must be very short — about one centimeter — and must be split 14:12.

The division was made several centimeters above the biopsy site for a safe margin 16:06. Tacking sutures on the serosa to the sidewall at three and six o'clock positions anchored the bowel in place 16:30. The anastomosis was constructed with a reinforcement layer to line up mucosa edge to mucosa edge 17:00.

What the Case Changes

The judgment here is not whether to operate — Hirschsprung disease requires resection — but how to distribute the work between abdomen and perineum. Proximal disease shifts the balance toward laparoscopy, not because laparoscopy is inherently superior, but because it protects the sphincters from the injury that comes with prolonged transanal dissection. The technical details — staying on the bowel wall during rectal dissection, preserving the mesenteric arcade, obtaining a proper full-thickness biopsy with submucosa — are not refinements. They are the difference between a pull-through that works and one that leaves a child incontinent.

Takeaways from this story

Proximal Hirschsprung transition zones favor combined laparoscopic-transanal approach to minimize sphincter stretch injury from prolonged perineal dissection.
Full-thickness biopsy must include submucosa to avoid missing hypertrophic submucosal nerves when seromuscular ganglion cells are present.
Rectal dissection must stay directly on the bowel wall; wide dissection risks pelvic nerve injury causing incontinence and urinary retention.
Preserving the mesenteric arcade along left colon and sigmoid is essential to achieve adequate reach into the pelvis without tension.

Proximal Hirschsprung Disease: Combined Laparoscopic-Transanal Pull-Through in a Neonate

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Case narrative · AI-written, human-reviewed

Presentation

A one-day-old infant presented with significant abdominal distension and bilious emesis 0:53. Plain abdominal radiography showed findings atypical for standard Hirschsprung disease 0:53. Suction rectal biopsy confirmed Hirschsprung disease with a rectosigmoid transition zone 0:53. The proximal location of the transition zone distinguished this case from more distal presentations and determined the operative approach 1:37.

The Decision Point

The central question was how to safely reach and resect a proximal transition zone while minimizing sphincter trauma. For non-rectosigmoid disease, a combined laparoscopic and transanal approach was chosen 5:03. The laparoscopic component serves two purposes: it allows direct visualization and biopsy of the transition zone, and — critically — it permits deep pelvic dissection that reduces the transanal work required 5:56. One discussant emphasized the morbidity associated with overstretching the sphincters through extensive transanal work 5:56. The standard became clear: transanal dissection should take under one hour in a primary pull-through 6:33.

The technical challenge was obtaining adequate reach without compromising blood supply or injuring pelvic nerves. The team emphasized staying close to the bowel wall during mesenteric dissection to reduce bleeding 11:00 and to avoid the incontinence and urinary retention that result from too-wide dissection of the distal rectum 11:42. "You need to be right on the bowel," one surgeon stated. "Because in the old days, the old Swenson done through the abdomen, patients were 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 arogenic case" [q2].

What the Team Did

After full body preparation, laparoscopic ports were placed at the umbilicus, right lower quadrant, and right upper quadrant, with the camera switched to the right upper quadrant for working access 8:16. A full-thickness biopsy was obtained — "cut a square, like a cube," with seromuscular and mucosal sides equal in size 7:09[q5]. The team mobilized the splenic flexure but waited for frozen section before taking mesentery 9:30. Pathology had to confirm ganglion cells and nerves less than 40 microns 10:00, and the specimen had to include submucosa to avoid missing hypertrophic nerves in the submucosal layer despite finding ganglion cells in the seromuscular layer 10:19.

Once the biopsy was confirmed adequate, mesenteric dissection proceeded close to the bowel wall 11:00. The arcade along the left colon and sigmoid was preserved to achieve sufficient reach into the pelvis 12:26[q1]. For this rectosigmoid disease, only distal branches of the inferior mesenteric artery were taken; more proximal disease would require taking the IMA itself 12:35. The dissection extended approximately five centimeters above the biopsy site for a safe margin 16:06.

The patient remained supine with legs wrapped and fastened to the ether screen 15:04. Transanally, the dentate line was identified and a mark placed one centimeter above it into the anal canal for the division line 13:02[q3]. The preference was Swenson full-thickness dissection in the areolar plane — "basically a bloodless plane" — rather than submucosal dissection with a cuff 14:12[q4]. If a cuff were used, it should be very short (about one centimeter) and must be split 14:12.

The anastomosis was performed with tacking sutures on the serosa to the sidewall at three and six o'clock positions to anchor the bowel in place 16:30. A reinforcement layer was placed to align mucosa edge to mucosa edge 17:00.

What the Case Changes

The operative sequence matters as much as the technique. Waiting for frozen section before committing to mesenteric division prevents resecting into hypertrophic nerve territory 9:30 10:00. Staying on the bowel wall during pelvic dissection protects autonomic nerves 11:42. Deep laparoscopic mobilization shifts work away from the sphincters and reduces the risk of overstretching 5:56 5:56. The transanal dissection, when properly supported by laparoscopic work, should take under one hour 6:33 — a concrete threshold that separates appropriate from excessive sphincter manipulation.

Takeaways from this story

Deep laparoscopic pelvic dissection reduces transanal work to under one hour, minimizing sphincter overstretching morbidity.
Full-thickness biopsy must include equal seromuscular and mucosal sides with submucosa to avoid missing submucosal hypertrophic nerves.
Wait for frozen section confirming ganglion cells and nerves <40 microns before taking mesentery to avoid resecting into diseased bowel.
Mesenteric dissection must stay on the bowel wall, not deep in mesentery, to prevent pelvic nerve injury causing incontinence and urinary retention.
Preserve the arcade along left colon and sigmoid for reach; take only distal IMA branches for rectosigmoid disease, full IMA for proximal disease.

Primary Pull-Through for Rectosigmoid Hirschsprung Disease in a Neonate

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Case narrative · AI-written, human-reviewed

Presentation

A one-day-old infant presented with significant abdominal distension and bilious emesis. Plain abdominal radiography was obtained, and suction rectal biopsy confirmed Hirschsprung disease with a rectosigmoid transition zone 1:37. The clinical picture differed from the typical distal presentation, prompting consideration of operative approach.

The Decision Point

Two operative approaches exist for Hirschsprung disease: the choice depends on whether the transition zone is proximal and complicated versus distal 1:37. For this rectosigmoid case, the team faced a fundamental question about technique. A purely transanal approach was possible but would require hours of dissection and risk overstretching the sphincters — a recognized source of long-term morbidity 5:56. The alternative was a combined laparoscopic and transanal procedure, accepting the additional complexity of port placement and laparoscopic mobilization in exchange for a safer, more controlled dissection.

The team chose the combined approach. For non-rectosigmoid transition zones, this is the preferred method 5:03. Deep laparoscopic dissection into the pelvis minimizes the transanal work required 5:56, and in a primary pull-through, transanal dissection should take under one hour 6:33.

What They Did

After bowel preparation with rectal irrigations and antibiotic prophylaxis, the infant was taken to the operating room with a full body prep. Port placement included an umbilical port and right lower and upper quadrant ports, with the camera switched to the right upper quadrant 8:16. Through the umbilical port, a full-thickness biopsy was taken — cut as a square cube with the seromuscular side the same size as the mucosal side 7:09. As one discussant emphasized, "It's 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 want to make sure that the seromuscular side is the same as the mucosal side" [q5].

The team mobilized the splenic flexure but waited for frozen section before taking mesentery 9:30. Pathology had to confirm two findings: ganglion cells present and nerves less than 40 microns in diameter 10:00. Critically, the biopsy had to include submucosa — ganglion cells might be present in the seromuscular layer while hypertrophic nerves persisted in the submucosal layer 10:19.

With pathology confirmed, mesenteric dissection proceeded close to the bowel wall rather than deep in the mesentery to reduce bleeding 11:00. This plane choice served a second purpose. "You need to be right on the bowel," one discussant stated. "Because in the old days, the old Swenson done through the abdomen, patients were 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 arogenic case" [q2]. The arcade along the left colon and sigmoid was preserved to ensure adequate reach into the pelvis 12:26. For this distal disease, only distal branches of the inferior mesenteric artery required division 12:35.

The patient remained supine with legs wrapped and fastened to the ether screen 15:04. Transanal dissection began with identification of the dentate line, marking approximately one centimeter above it into the anal canal for the division line 13:02. As one surgeon framed it, "So I think of this part as do no harm to the dentate line nor to the sphincters" [q3]. The team performed a Swenson full-thickness dissection in the areolar plane — described as bloodless — rather than a submucosal dissection with cuff 14:12. If a cuff were used, it should be very short, about one centimeter, and must be split 14:12.

The bowel was divided approximately five centimeters above the biopsy site for a safe margin 16:06. Tacking sutures on the serosa to the sidewall at three and six o'clock positions anchored the bowel in place 16:30. The anastomosis was constructed with a reinforcement layer to align mucosa edge to mucosa edge 17:00.

What the Case Changes

The combined laparoscopic-transanal approach transforms the risk profile of neonatal Hirschsprung repair. By limiting transanal dissection to under one hour and performing the bulk of mobilization laparoscopically, the procedure minimizes sphincter trauma while maintaining oncologic principles — staying on the bowel wall to preserve pelvic autonomic nerves, obtaining adequate proximal margin with frozen section confirmation, and preserving mesenteric arcade for reach. The technical discipline required at frozen section — confirming both ganglion cells and nerve caliber, insisting on submucosal tissue — prevents the error of pulling through transition zone. What appears as surgical choreography is actually a sequence of safeguards against the known modes of failure.

Takeaways from this story

Combined laparoscopic-transanal approach limits transanal dissection to under one hour, reducing sphincter overstretching morbidity.
Frozen section must confirm ganglion cells AND nerves <40 microns; biopsy must include submucosa to avoid missing transition zone.
Mesenteric dissection stays on the bowel wall, not deep in mesentery, to prevent pelvic nerve injury causing incontinence.
Full-thickness biopsy must be cut as a cube with seromuscular side equal to mucosal side for adequate pathologic assessment.
Preserve the arcade along left colon and sigmoid; for distal disease take only distal IMA branches to maintain reach.

Topic overview

A surgical technique discussion of Hirschsprung disease operative management, focusing on a one-day-old with rectosigmoid transition zone. The panel covers laparoscopic-assisted transanal pull-through technique, emphasizing full-thickness biopsy requirements (ganglion cells, nerves <40 microns, submucosa present), mesenteric dissection staying close to bowel wall to preserve nerve supply, and anastomotic technique. Critical teaching points include avoiding sphincter overstretching during transanal dissection and the importance of short or no muscular cuff to prevent complications.

Key takeaways

Full-thickness biopsy must include submucosa to detect hypertrophic nerves missed in seromuscular-only samples. (10:19)
Mesenteric dissection must stay close to bowel wall; wide dissection of distal rectum causes incontinence and urinary retention. (11:00)
If using a muscular cuff, keep it very short (~1cm) and split it to prevent obstructive complications. (14:12)
Avoid sphincter overstretching during transanal dissection; deep laparoscopic work minimizes transanal extent needed. (5:56)
Wait for frozen section confirming ganglion cells and nerves <40 microns before taking mesentery. (9:30)

Keywords

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

Hashtags

#HirschsprungDisease #PediatricSurgery #ColorectalSurgery #SurgicalEducation

Transcript

Click "Show Transcript" to view the full text (17030 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 love iPEGS content. They got a channel too. So download the Stay Current and Pediatric Surgery app. It's in the Apple App Store. It's in the Google Play Store. But until then, enjoy the episode. So the next case is a one-day-old and presents with significant abdominal distension and bilious 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 Hirschsprung's picture. So a head-scratcher for Todd. Do you think it was for Dr. Levitt too? A little bit more complicated than the first case. Yeah, it's not so obvious. So to finish this case, rectal biopsy, suction rectal biopsy confirms the diagnosis of Hirschsprung'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 going to talk about the operative technique for Hirschsprung's disease. I'm Rod Girardo from Cincinnati Children's, and this is the colorectal quiz. Rod, you are to colorectal surgery, as Michael Barbaro is through the New York Times and The Daily. So thank you for all your efforts. That's flattering. I appreciate it. Thank you. That's Dr. Mark Levitt at Children's National Hospital in Washington, D.C. 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. Dr. Levitt and Dr. Frischer at Cincinnati Children's are talking about their former fellow, Dr. Aaron Garrison, who was also on the call. We thought it might turn into a three-year fellowship, but he was able to skate out in two. Once a fellow, always a fellow. That's the truth. That's so true. 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, D.C. So for those of you who haven't been following along every week, Dr. Levitt and Dr. Frischer gave us two different Hirschsprung 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 want to focus this week on the 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 Dr. Levitt and Dr. Frischer are talking about. You know, Mark, I think the two of us talking, have you ever seen a Muppet show and there's two old guys in the balcony? Dr. Badillo and Dr. Garrison agreed that those two Muppets were basically what Dr. Levitt and Dr. Frischer 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, smiling at you. Belly's flat. Biopsy showed Hirschsprung as we discussed. Should we go to the OR? Yeah, I think definitely ready for the OR. You know, a patient who's in our NICU, we wouldn't necessarily bowel prep. We would probably, especially if they're breastfed. So we would keep irrigations going, though, until we've got OR time. We have some antibiotics and some blood available just for to be safe, although typically, obviously, don't need that for this operation. And then we go to the OR and decide about our approach. With this contrast study, I think my favorite approach is to combine through laparoscopy and transanaly. So I would do a full body prep and start the procedure from the abdomen. And Dr. Badillo agreed. No, I mean, I like Aaron's approach. I like laparoscopy. I don't like to have surprises. And if there's, if it's not a recto 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 laparoscopic dissection into the pelvis so that you have very minimal transanal work to do. I think, unfortunately, you know, Jason and I and you and Aaron and Andrea see a lot of the morbidity associated with first-brown disease and the overstretching of the sphincters, which can be done if you do an extensive transanal amount of work, is really a morbidity that needs to be avoided. And laparoscopy helps with that. And Dr. Frischer is even more strict about the stretching. I previously used to do this transanal and it would take a few hours. Now the transanal dissection should be usually way under an 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 sort of umbilical approach. We do an incredible amount of work through an umbilical approach, so I want to keep that option in mind. Dr. Garrison tried to keep us on track. Can we talk about basics for a second, though, about like actually obtaining the biopsy? Because I think there are 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 eight millimeter fascial incision, so it gives you just a little bit more room to work and do the biopsy kind of at the umbilicus. It's 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 want to make sure that the seromuscular side is the same as the mucosal side. And then, of course, you can suture it up extracorporeally. 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 want to give us some insight of how you set up, if you're doing this laparoscopically, how you set up your ports? So, obviously, 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, because the sigmoid's very floppy, where do you put that? Um, that, I kind of, depends right over the sigmoid, really, but that, that one's variable. 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 agree. It's fascinating. It's fascinating that you would bring that up, because when you were the fellow, boy, did we have to fall over ourselves. I just tried to make you look good. I know, I have vivid memories of all of that. Okay, guys, let's get back to the matter at hand. So, we have a recto sigmoid 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 are hoping comes back as good news on the frozen section will reach. I usually don't start taking mesentery until 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 don't want to 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 seromuscular layer and hypertrophic nerves in the submucosal layer. All right. So, let's say the biopsy comes back. And just like Dr. Badia says, we're good to go, then what? All right, Aaron. Now, 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? Well, at that point, then, you know, we're proceeding with our pull through. And there's a variety of options. We've been using the just right sealer a little more to dissect and take some of those mesenteric vessels. The hook works nicely as well. We try staying just 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 a little less bloody in that plane. And so, you know, we would just start somewhere where it's easy and make a hole in the mesentery, dissecting through it, and then cauterizing up and down all the way into the pelvis and both leaves of the mesentery. You know, I want to 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 bowel. Because in the old days, the old Swenson done through the abdomen, patients were 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 arogenic case. 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 that arcade along the left colon and sigmoid colon so you could get enough distance to reach the pelvis. Dr. 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 going to see the transanal exposure with the Lone Star retractors. And here's Dr. Bedeo. So I think of this part as do no harm to the dentate line nor to the sphincters. I like to identify the dentate line and then make a mark about a centimeter above that into the anal canal. And that's going to be the line that we're going to 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 going to advance to cover the dentate line. And then the third maneuver is at your... Where you open the mucosa and start your dissection. They'll bring that all underneath the pins. And then you'll continue your dissection superiorly. That third 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 Allman, the Swabson 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. But the Suaveists out there have been making that cuff shorter and shorter and shorter. Jack Langer will do about a one centimeter cuff now. And Luis told me that he's now doing a Swenson. So if you're going to do a cuff because you feel compelled to do it, make it very, very short. And that's something we might call a Swenson. And you split the cuff. Yeah, you must split it. You must split the cuff. Again, Dr. Garrison was quick to point out that we might have forgotten something. Yeah, I don't think we 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 like keeping the patient supine, having the legs wrapped with the full body prep and fastening the legs with the 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 gives an opportunity for everybody to get involved. The anesthesiologist can hold the clamp. Sometimes you got to wake them up. All right, let's get back. So now that Aaron brought us properly positioned a patient, even though we were... In our supine patient, you're in the Swenson plane, and if you've done a lot of really good work laparoscopically, then that dissection shouldn't take you too long, and you're going to meet your dissection from above. And maybe get a gusher of fluid or something, and you know that you've gotten into that peritoneal space. So you're bringing that bowel through. You'll find your biopsy site. You like to go above that. How far above do you like to go? No magic number. I think you can really see that the bowel looks good, and that's probably influenced where you did your biopsy to begin with. And then to give yourself a five-centimeter margin or so above that is very safe, I think. Okay, so we did our pull through. We have a safe landing zone. Let's talk about the anastomosis. I do like putting two kind of tacking sutures on the serosa to the sidewall. 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 sidewall in the kind of three and six o'clock positions. Open up the anterior half of the anastomosis and anchoring sutures there. And I usually use 4-0 micro pops for these. Set up kind of 12, three, and six o'clock and put the in-betweeners before transecting the rest of the bowel. All four of the surgeons on the call agreed that the reinforcement layer that Dr. 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 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 were both 11 years old. And the one kid said to the other, hey, what are you? Are you having surgery? What are you having surgery for? And he said, well, they tell me 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 going to be going home tomorrow. 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 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 delivery, too. Good delivery. Okay. Okay. There you have it. The surgical technique from four expert pediatric colorectal surgeons. But that was the straightforward case. Next week, we're going to talk you through the more complicated case that we presented a couple 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 Dr. 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, Dr. 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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