Laparoscopic Duhamel: Pediatric Surgery Difficult Cases 2013

Um, so if we're gonna start off with the first one, which is the new laparoscopic Duhamel procedure. So let's roll that video, Stefan. Doctor Abelo and Doctor Ce from the minimally invasive pediatric Surgery Group and High Complexity clinic in Barraquilla, Colombia present the new Duamel. The new duo malaba you pull through consists of a laparoscopic transretrorectal rectal sigmoidectomy. It was designed to eliminate the septic intraabdominal step, to avoid intraabdominal sutures, to be able to determine the length of the residual stump, and to assure a more secure colorectal anastomosis. The first step, begin by creating a retrorectal space. This is our way of exposing the anorectal mucosa and visualizing the dentate line. Proceed then to make the first incision with the electroc artery. Bovi on coagulate, cutting in the following way at this level. In this schematic, the dotted line indicates the incision of the posterior wall of the rectum 1.5 centimeters from the dentate line. Once the incision is complete, you proceed digitally to find the retrorectal space. Digitally dissect until falling into the space. The tissue is easily dissected, which allows access to the retrorectal space to the sacral promontory. Dissect along the lateral walls of the rectum approximately 50% of the circumference of the posterior rectal wall to leave ample room and leave a reed clamp at this level posteriorly which we will use to visualize when performing the laparoscopy. Here you can see the clamps retracting the anterior and posterior rectal borders and in the middle the retro rectal space. This is the schematic representation of the location of the clamp in the retroperitoneum. Again, you are leaving a reigned clamp posteriorly in the retroperitoneum. Here you can see the placement and location of the clamp through the rectal space in the peritoneum. The second step is the laparoscopic endopelvic dissection and skeletonization of the colon. We begin with the hook cautery, and once we have this window dissected, we begin to proceed to the reorectal space and to mobilize the colon, ligating the sigmoid like you see here. Once the intestine has been mobilized, we will identify the clamp at the bottom of the pelvis, which we open as such with a ligature or bipolar device, and you can see that it is basically a bloodless process with which you can very clearly see the anatomy. Here we enter the abdomen with the clamp. You can see the escape of smoke, which we can control by clamping the rectum. Now comes the descent to the peritoneum. With the clamp. We grab the sigmoid in this way by the mesenteric handle, and we pull into the retrorectal space through that initial incision. With the handle externalized, we place forceful traction on the distal segment, which is anterior. Staple linearly with a GIA stapler 75 millimeters transversely. Which can then be reinforced with PDS or vicral invaginating sutures. Next, we return the rectal stump to the abdomen and keep the colonic limb to define the level of anastomosis. The level at which to cut is defined by the pathologic markers intraoperatively by frozen suction or by mapping a transition sewn with previous suction biopsies. After cutting, we proceed to make the anastomosis of the posterior wall of the rectum and the posterior wall of the descending colon. To finish the final anastomosis with the Martin technique and modification, leaving a very ample window with minimal chance of stenosis. Here you can see the modification of Martin. And a schematic representation of the anastomosis finished. This is the anastomosis 6 months postoperatively via colonoscopy of the residual pouch. This pouch is approximately 3 centimeters in an asymptomatic patient. Some problems that can occur are accumulation of feces, constipation, and fecal impaction when the stump is left too long. Still, one can see through this video that it is easy to divide the residual stump if necessary. This is the healthy colon. We recommend this technique for all pediatric patients, including patients with very dilated colons. It is reproducible, easy, and fast, and there is a minimal incidence of constipation and stenosis. Thank you. OK. Uh, so I wanted to open this up, uh, for comments, and, uh, Doctor Abello, are you there? Can you hear us? Cristobal Abeok, are you there? I see you're on the phone line. Uh, if you ever get connection, just let us know. Um, let me open this up to the, uh, virtual faculty. Uh, Cathy, do you have any comments about this? Have you ever seen this done or anything like it? Uh, no, I think, I think the issue of doing everything extraperitoneally is nice. Um, I, I just looked there that her in the, in the technique that there looked like there was quite a, a, a long residual stump above your anastomosis or above your, um, your staple line and my screen just went out. I don't know if that's. So, I mean, I think it's, I think all of these things are good adjuncts to our, to our um armamentarium for Hirschsprung's disease and I think it's the more techniques you know, the more you'll be able to tailor to the appropriate patients. Yeah, um, you know, I thought he did demonstrate in the colonoscopy, or not colonoscopy, but in the scope afterwards that there was a relatively small, um, um, stump there. Um, but, but I think that he was also saying that you could go in and, and shorten that if you needed to by stapling that connected area. Um. Did you have comments that either of you wanted to make? I guess, uh, I mean, it's a nice, it's a nice, um, way to do a Duhamel if, uh, Duhamel is, is your operation of choice, and I think there are advantages and disadvantages to each of the different operations. The thing that I was a little concerned about though, um, at the beginning, it looked like you were stretching those sphincters pretty aggressively and, uh. That's one of the mistakes that people make when they're doing a transanal pull through, uh, is to stretch the sphincters and do the operation on the inside. Really, it should be done by pulling everything out and doing it on the outside without stretching the sphincters, and I, I worry that you may be damaging the sphincters, uh, a little too much. Yeah, I think that's a good point. And Doctor Abello, if you ever get on the phone to answer some of these comments, just let us know. Just chime in. Um, can I? Yes, go ahead. Uh, well, we have a lot experience with doing a laparoscopic DML procedure, and in the early days when we had, uh, difficulties still to, to close the stump, we also, uh, brought the, the colon outside and, and, and, and, uh, transected it outside and then put it back again. Uh, with increased experience, uh, we don't do it anymore, uh, and we leave a pretty short stump. Uh, and even if you have some more stump left, you know, you can still trim it later on before closing the, uh, the stump down. Uh, and that is, uh, then don't, you don't have to overstretch like, uh, It was said just now that, uh, that you overstretched the anus. So you do actually all the dissecting from the inside, and more, also, we use the, the end of GIA, uh, for making the site to site anastomosis and therefore you can also use it in even neonates, uh, so you can do it very early, at, at a very early age. Um, and you don't really have to leave a, a real pouch behind. So you can. I know, I know the, No, I know the concept about, uh, say Doctor Langer um Doctor Evander, uh, um. Doctor Abella, we're having a hard time hearing you. Um, So maybe uh you can answer your comments in the chat box because we're having a hard time hearing your audio um careful if you don't search the the the the speakers very much yeah uh we separate the para separateator uh gen gentle, gently, and, and we can. We don't have a a No problems with uh the very, very uh location, the incision with the electrode also. Alright