Sphincter Reconstruction for Patients with Soiling after a Pull-Through for Hirschsprung Disease

Who's speaking

• Speaker 1

Chapters

• 0:05Case Presentation and Background — Introduction of a 10-year-old with post-Hirschsprung pull-through incontinence, anatomic findings, and current management with Malone appendicostomy.
• 1:01Preoperative Assessment — Physical examination findings and 3D anorectal manometry demonstrating absent sphincteric contraction, particularly anteriorly.
• 1:37Surgical Technique - Dissection Phase — Prone positioning, circumferential exposure, dissection of pull-through from external sphincter muscle in areolar plane to 3-3.5 cm depth.
• 3:33Surgical Technique - Reconstruction Phase — Circumferential tacking of external sphincter muscle to bowel wall with absorbable sutures, starting anteriorly, followed by mucosal-to-skin closure.
• 4:37Postoperative Plan and Outcomes — Planned rehabilitation with continued antegrade flushes to practice voluntary control, with objective improvement confirmed on repeat 3D manometry.

Key claims

• 0:05The patient is a 10 year old boy with a prior pull-through for Hirschsprung's disease who suffered from fecal incontinence for many years — Speaker 1
• 0:11Physical exam showed a patulous anus and an absent dentate line — Speaker 1
• 0:25These anatomic problems result from an overstretching of the anal sphincters and a dissection started too low during the initial procedure — Speaker 1
• 0:35A Malone appendicostomy was given for antegrade flushes to manage incontinence — Speaker 1
• 0:41The patient was able to be clean and socially continent, albeit mechanically, with the Malone — Speaker 1
• 0:47The novel sphincter reconstruction technique aims to improve the ability to squeeze the anus closed and enable voluntary bowel movements — Speaker 1
• 1:19Three-dimensional anorectal manometry confirmed objectively the absence of good sphincteric contraction, particularly on the anterior aspect — Speaker 1
• 1:37The operation is performed in prone position — Speaker 1
• 1:40Lone star retractor pins are placed just at the skin level, as there is no dentate line to preserve — Speaker 1
• 2:08The dissection is performed in the plane between the bowel wall and the surrounding sphincter muscle — Speaker 1
• 2:21The plane between the bowel and the muscle frees up easily, as the muscle is not very adherent to the pull-through — Speaker 1
• 2:29A nice areolar plane exists between the bowel and muscle, allowing visualization of the external sphincter muscle circumferentially — Speaker 1
• 2:53The external sphincter muscles need to be more firmly attached to the distal pull-through to provide adequate squeeze to close the anus — Speaker 1
• 3:02If the patient can detect the presence of stool in the anal canal, they will be able to close the anus in time to avoid an accident — Speaker 1
• 3:11The patient is planned to practice sphincter control during their antegrade flushes and is anticipated to get better and better at holding in their flush — Speaker 1
• 3:18The depth of dissection measures 3 to 3.5 centimeters — Speaker 1
• 3:24Deeper to the dissection location is ischiocrectal fat — Speaker 1
• 3:33The muscle is tacked to the bowel circumferentially, starting anteriorly, which was the most problematic area noted on the manometry — Speaker 1
• 3:57Absorbable sutures are used from the seromuscular bowel layer to the muscle — Speaker 1
• 4:15After tacking is complete, the mucosal edge is sutured back to the skin circumferentially — Speaker 1
• 4:28Digital exam confirms that the anus is supple and easily distensible, but now compressed by the surrounding external sphincter — Speaker 1
• 4:37After a period of time with continued antegrade flushes and hopefully improvement in control, the plan is to allow the patient to have their own bowel movements and demonstrate their own capacity for voluntary control — Speaker 1
• 4:54Repeat three-dimensional anorectal manometry confirmed objectively an improvement in the symmetry of the muscles around the pull-through and in their increased tone — Speaker 1

Cases discussed

• 0:0510-year-old boy with fecal incontinence following Hirschsprung pull-through, managed with novel sphincter reconstruction