The Colorectal Quiz Episode 4

Published: 2021-02-22

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Marc Levitt

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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
Mark Levitt — guest
Jason Frischer — guest
Andrew Badillo — guest
Aaron Garrison — guest

Chapters

0:00Introduction and case presentation — Introduction to the colorectal quiz podcast and recap of two Hirschsprung cases: one straightforward rectosigmoid transition and one proximal transition with bilious emesis.
2:42Preoperative preparation and approach selection — Discussion of timing for surgery, bowel preparation strategy, and rationale for combined laparoscopic-transanal approach versus pure transanal technique.
5:40Laparoscopic technique and biopsy — Port placement, full-thickness biopsy technique using anchor port, frozen section requirements including ganglion cells and nerve caliber, and splenic flexure mobilization.
10:48Mesenteric dissection — Technique for mesenteric vessel division staying close to bowel wall, preservation of marginal arcade, and decision-making about IMA division based on transition zone level.
12:51Transanal dissection — Patient positioning options, Lone Star retractor placement protecting dentate line, Swenson versus Soave dissection planes, and meeting the laparoscopic dissection.
15:37Anastomosis and closure — Pull-through technique, margin above biopsy site, lateral tacking sutures to pelvic sidewall, and mucosa-to-mucosa anastomotic technique.

Key claims

6:00Laparoscopic approach allows deep pelvic dissection minimizing transanal work and avoiding sphincter overstretching — Aaron Garrison
6:33Transanal dissection in primary pull-through should take under one hour when adequate laparoscopic dissection is performed — Jason Frischer
7:09Full-thickness biopsy should be a cube with seromuscular side matching mucosal side dimensions — Aaron Garrison
10:00Frozen section must confirm ganglion cells and nerves less than 40 microns — Andrew Badillo
10:19Frozen section biopsy must include submucosa to avoid missing hypertrophic nerves in submucosal layer — Mark Levitt
11:00Mesenteric dissection should stay close to bowel wall to minimize bleeding and avoid injury to nerves — Aaron Garrison
11:42Historical Swenson operations done through abdomen with wide distal rectal dissection caused incontinence and urinary retention from nerve injury — Mark Levitt
12:26Marginal arcade along left colon and sigmoid must be preserved to achieve adequate length for pelvic reach — Andrew Badillo
12:43For distal disease only distal IMA branches need division; for left colon disease IMA itself may require division — Jason Frischer
13:02Transanal mucosal incision should be made one centimeter above dentate line — Andrew Badillo
13:02Lone Star retractor pins advance in three stages: at skin to identify dentate, covering dentate, then underneath pins at mucosal opening — Andrew Badillo
14:12Swenson full-thickness dissection follows areolar plane which is essentially bloodless — Mark Levitt
14:12If Soave muscular cuff is used it should be very short, approximately one centimeter, and must be split — Mark Levitt
16:06Five-centimeter margin above biopsy site is safe for resection — Aaron Garrison
16:30Lateral tacking sutures to pelvic sidewall at three and six o'clock positions anchor the pull-through — Aaron Garrison
17:00Reinforcement layer is critical to align bowel edges for mucosa-to-mucosa anastomosis — Rod Girardo

Cases discussed

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

Open questions

What is the optimal technique for more proximal transition zones requiring extended colonic resection
What is the minimum acceptable length for Soave muscular cuff if that technique is chosen

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.

Minimizing Morbidity in Primary Hirschsprung Pull-Through: Technical Refinements That Matter

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 specialists · Teaching arc · AI-written, human-reviewed

Laparoscopy protects the sphincters

The most important technical decision in primary pull-through is how much work you do from above versus below. Deep laparoscopic pelvic dissection minimizes transanal manipulation, which directly prevents sphincter overstretching — a major source of long-term morbidity 6:00. When adequate laparoscopic mobilization is performed, the transanal portion should take under one hour 6:33. Surgeons who still work primarily transanally are creating problems their patients will live with for years.

The biopsy must answer three questions

Frozen section exists to confirm you are pulling through normal bowel, but "normal" has three components. First, ganglion cells must be present. Second, nerve caliber must be less than 40 microns — hypertrophic nerves indicate transition zone even when ganglion cells are present 10:00. Third, the pathologist must see submucosa, because hypertrophic nerves may hide in the submucosal layer while the seromuscular layer looks normal 10:19. A full-thickness biopsy shaped as a cube — seromuscular side matching mucosal side dimensions — ensures the pathologist has what they need 7:09. If your pathologist reports back without commenting on submucosa, the biopsy was inadequate.

Mesenteric dissection stays on the bowel wall

The plane of mesenteric dissection determines whether you injure pelvic nerves. Stay close to the bowel wall rather than working deep in the mesentery 11:00. This is not just about bleeding — it is about avoiding the nerve injury that caused incontinence and urinary retention in historical Swenson series when surgeons dissected the distal rectum too widely 11:42. The marginal arcade along the left colon and sigmoid must be preserved to achieve adequate length for pelvic reach 12:26. For distal disease, only distal IMA branches require division; for left colon disease, the IMA itself may need to come down 12:43.

Transanal dissection begins one centimeter above the dentate line

The mucosal incision is made one centimeter above the dentate line 13:02. Lone Star retractor pins advance in three stages: first at the skin to identify the dentate line, second covering the dentate line, third underneath the pins at the mucosal opening 13:02. That third pin position is the one that makes the dissection straightforward. The goal is to avoid any injury to the dentate line or sphincters — this is the "do no harm" portion of the operation.

Full-thickness dissection follows a bloodless plane

Swenson full-thickness dissection follows an areolar plane that is essentially bloodless 14:12. If a Soave muscular cuff is used, it must be very short — approximately one centimeter — and must be split 14:12. Leaving a long cuff creates the complications the Soave technique was supposed to avoid. A five-centimeter margin above the biopsy site is safe for resection 16:06.

The anastomosis requires lateral anchoring

Lateral tacking sutures to the pelvic sidewall at three and six o'clock positions anchor the pull-through and prevent retraction 16:30. These are not technically a second layer, but they stabilize the bowel before the mucosal anastomosis. The reinforcement layer is critical to align bowel edges so that mucosa meets mucosa 17:00 — this alignment, not the suture material or technique, is what determines whether the anastomosis heals cleanly.

The operation succeeds or fails on whether you protect the sphincters during dissection, confirm normal bowel on frozen section, stay on the bowel wall during mesenteric mobilization, and align the anastomosis precisely. Everything else is preference.

Takeaways from this story

Deep laparoscopic dissection keeps transanal work under one hour and prevents sphincter overstretching morbidity
Frozen section must confirm ganglion cells, nerves under 40 microns, and presence of submucosa to avoid false negatives
Mesenteric dissection on the bowel wall rather than deep mesentery prevents pelvic nerve injury causing incontinence
Swenson full-thickness dissection follows a bloodless areolar plane; Soave cuffs must be one centimeter and split
Lateral tacking sutures at three and six o'clock anchor the pull-through before mucosal anastomosis alignment

Topic overview

A multi-surgeon discussion of operative technique for Hirschsprung's disease with rectosigmoid transition zone. The panel covers laparoscopic-assisted transanal pull-through, emphasizing the importance of deep laparoscopic pelvic dissection to minimize transanal sphincter stretching, full-thickness biopsy technique with frozen section confirmation of ganglion cells and nerve caliber <40 microns, mesenteric vessel management staying close to the bowel wall, and Swenson versus Soave anastomotic approaches. The surgeons stress avoiding sphincter injury and maintaining a bloodless areolar dissection plane.

Key takeaways

Deep laparoscopic pelvic dissection minimizes transanal work, reducing sphincter stretch and keeping transanal time under 1 hour. (6:00)
Frozen section must confirm ganglion cells AND nerves <40 microns; include submucosa to avoid missing hypertrophic nerves. (10:00)
Swenson full-thickness dissection follows an essentially bloodless areolar plane; avoid wide rectal dissection to prevent nerve injury. (11:42)
If using Soave muscular cuff, keep it very short (~1 cm) and split it to prevent obstruction. (14:12)
Preserve marginal arcade along left colon/sigmoid for adequate pelvic reach; stay close to bowel wall to minimize bleeding. (11:00)

Keywords

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

Hashtags

#HirschsprungDisease #PediatricSurgery #ColorectalQuiz #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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