IPEG 2020 TOP ABSTRACT: Robotic excision of redundant rectal pouch in HSCR after Duhamel procedure
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What the experts said
Patient was a 5-year-old boy with Hirschsprung disease who underwent leveling colostomy at birth.
Patient underwent Duhamel pull-through at 10 months of age, performed at another institution.
Although immediate postoperative period was uneventful, the child progressively developed severe constipation and soiling.
Barium enema showed suspected redundant rectal pouch, which was confirmed at lower GI endoscopy.
Treatment alternatives for redundant rectal pouch include stapled division with or without laparoscopic assistance, redoing, and pouch excision.
Robotic pouch excision was scheduled after a period of bowel management.
The redundant rectal pouch was located on the posterior right side with a long septum.
The da Vinci SI robotic system was used for the procedure.
Identification of the blind ending of the rectal pouch was difficult due to significant adhesions and scarring tissue.
The pull-through colon was biopsied to rule out residual aganglionosis.
Monopolar electrocautery was used to help dissect the rectum from surrounding structures.
Meticulous dissection was needed to avoid tearing and contamination when approaching the posterior anastomosis.
The bladder and vas deferens were dissected anteriorly to allow safe insertion of a linear stapling device.
The pouch was divided as close as possible to the previous anastomosis using a linear stapling device.
The suture line was positioned below the peritoneal reflection.
The parietal peritoneum was closed with a running Prolene suture.
The postoperative course was uneventful with progressive symptom resolution.
Soiling resolved postoperatively.
At 24 months postoperatively, the child is thriving well and asymptomatic.
Lower GI endoscopy at 12 months postoperatively showed a residual rectal pouch shorter than 1 centimeter without inflammation and symptoms.