Alessio Pini Prato, MD; Rossella Arnoldi, MD; Claudio Carlini, MD; Paolo Nozza, MD; Luigi Montagnini, MD; Umberto Bosio Center for Digestive Diseases, The Children Hospital, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy, EU
A male patient with Hirschsprung disease underwent a Duhamel procedure when he was 5 months of age. Postoperatively, he developed increasing obstructive symptoms, soiling, and painful passage of stools. When he was 5 year-old, he underwent examination under anaesthesia, barium enema and lower endoscopy that showed a redundant rectal pouch. Rectal suction biopsies ruled out residual disease. He was therefore scheduled for redundant rectal pouch excision. The procedure was performed with a DaVinci Si robotic system and was carried out without intraoperative complications. The whole procedure lasted a total of 260 minutes including 60 minutes laparoscopic division of peritoneal adhesions and a further 30 minutes of docking time. Postoperative course was uneventful. The child was discharged on postoperative day 7. Symptoms improved and progressively settled. The child is now fine, back to normal continence with no more episodes of soiling nor pain and an overall normal quality of life.
We present a case of robotic excision of redundant rectal pouch and Eschmann's disease after a Duomal procedure. We have nothing to disclose. This case reports of a 5 year old boy with a Lux sangentiner's disease who underwent labeling colostomy at birth and a subsequent duomal pull through at 10 months of age that was performed elsewhere. Although immediate postoperative period proved to be uneventful, the child progressively developed severe constipation and soiling. He was admitted to Umberto Bossa's Center for Digestive Diseases, the Children's Hospital in Alessandria, Italy, and underwent a barium enema showing suspected redundant rectal pouch, which was confirmed at low GI endoscopy. We therefore had to choose amongst a number of alternatives including stapled division with or without laparoscopic assistance, redoing, and pouch excision. We decided to opt for robotic pouch excision that was scheduled after a period of bowel management. This picture shows the redundant rectal pouch on the posterior right side with a long septum. This was confirmed at endoscopy showing the blind and redundant pouch above in this picture and the pull through column below. After a long and time consuming adsolysis, the da Vinci SI robotics system was docked and the dissection started in order to identify the blind ending of the rectal pouch. This turned out not to be that easy due to the significant amount of adhesions and scarring tissue. Once the pouch was identified, we started freeing it from the bladder in front and from the pull through column that was biopsied to rule out residual inevvative issues below. The isolation of the pouch was continued downwards, keeping particular attention to avoid bleeding and to maintain a clean field of view throughout the procedure. Monopoar electrocuterry was used to help in dissecting the rectum from the surrounding structures. Paying particular attention to proceed towards the posterior anastomosis between the pouch and the previously pulled through column, meticulous dissection was needed to avoid tearing and contamination. Once the posterior anastomosis with the pull through colon was identified, the pouch was freed circumferentially, paying particular attention to dissect the bladder and the vas anteriorly in order to allow a safe insertion of a linear stapping device that was used to divide the pouch as close as possible to the previous anastomosis. At the end of the procedure. A safe and well sealed suture was achieved. This sitting well below the peritoneal reflection, as you can see in this nice view of this region. Once the bleeding was controlled completely, the parietal peritoneum was closed with a running suture, for all prolene suture, to conclude the procedure. The postoperative course was uneventful. The child recovered well with symptoms that settled progressively during the post-operative period. Soiling settled the same. The child is now 24 months postoperatively, and is thriving well and asymptomatic. A lower GII endoscopy performed 12 months postoperatively showed a residual rectal pouch shorter than 1 centimeter without inflammation and symptoms, and I want to thank all the colleagues working at Humberto Boso Center for Digestive Diseases with their unique multidisciplinary approach to serve the best for our patients.
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