Laparoscopic pull-through for Hirschsprung disease updated 2024

We present a case of an operation for Hirschprung's disease, a laparoscopic assisted pull through using the Swenson technique. Here you see a typical case with a sigmoid transition zone on the contrast enema. To set up for laparoscopy, a total body prep is used. Here we show the location of the intended port placement. Access at the umbilicus begins the case with a 5 millimeter trochar, and the abdomen is insufflated. To maximize exposure to the view of the pelvis, the camera is moved to a port site at the right upper quadrant. The operating surgeon should stand comfortably at the patient's right shoulder. The surgeon's left hand goes then to the umbilical port, and the right hand goes to the right lower quadrant port. An assisting port is used to hold up the sigmoid colon, which goes in the left upper quadrant. Laparoscopy is used to do the leveling biopsy. We bring the sigmoid out the umbilical port and do an extra corporeal biopsy full thickness. Once the level is confirmed, laparoscopy is then used to take down the attachments of the left colon if needed from the left retroperitoneum to dissect into the deep pelvis. And to take the mesenteric arcade distal to the biopsy site, preserving the sigmoid arcade to the location of the intended pull through. Once the laparoscopic mobilization is complete, exposure of the anal canal is performed using the Lone Star pins. The pins are placed to show the dentate line. They are then placed deeper so the dentate line is hidden and no longer visible. The purple line of Lee is traced 0.5 centimeters proximal to the crypts, preserving the anal canal. Silk sutures are placed which facilitate a circumferential dissection. Into the Swenson plane which is seen here with the areolar tissue visualized. The bowel is mobilized full thickness, and the prior dissection done laparoscopically is reached, allowing for the rectosigmoid to be pulled through to the biopsy site. And finally, the coloanal anastomosis is performed. Ports are placed and the camera is moved to the high right upper quadrant. A biopsy is taken from the mid to upper sigmoid and confirms ganglion cells. Our dissection begins on the upper rectum, carefully removing fat and dissecting at the peritoneal reflection. This segment of lower sigmoid appears leathery. The more proximal sigmoid appears healthy. We check the upper sigmoid to see if it stretches down into the pelvis. Note the arcade. We now dissect more proximately trying to come through to the other side. Care must be taken to check for the left ureter. The arcade to the biopsy site is preserved and the mesentery taken adjacent to the bowel distal from this location. We now continue our dissection into the deep pelvis. We inspect the arcade and ensure there is a good marginal branch from the IMA. Everything distal to this branch has been dissected with the ligature. We make sure our intended section of bowel easily reaches the perineum for the ultimate pull through to the coloanal anastomosis. Once this is complete, we lift the legs and set up for our transanal dissection. With the legs in the lithotomy position, the Lone Star pins are placed to expose and protect the anal canal. The purple line of Lee is marked 0.5 centimeters proximal to the dentate line, which is no longer visible because it has been hidden by the pins. A transanal dissection begins. We dissect in a full thickness, Swenson-like plane. And quickly are able to break through to the location of our previous dissection done laparoscopically from above. It is then pulled through, maintaining its orientation. The bowel is marked to avoid twisting it. And now we begin our anastomosis, serum muscular bites to the sphincter, and then a second layer, mucosa to mucosa. A nice trick is to pull apart opposing mosquito clamps and suture between them, which takes away any size discrepancy. The Lone Star retractor is removed and we take a final look at the pull-through laparoscopically.