Technique: Laparoscopic Assisted Pull-through for Hirschsprung's Disease

This video represents a laparoscopic assisted pull-through procedure for Hirschprung's disease in a newborn using the JRS 3 millimeter sealer as the primary mode of dissection. The patient is placed transversely on the table with the surgeon and the assistant initially standing at the patient's head for the laparoscopic portion of the procedure. Here you can see the camera is placed around the umbilicus, and the right and left hand ports are placed in the mid to lower quadrants depending on the size of the baby. Here is the baby positioned on the table. Again. This is a newborn weighing 3.2 kg. Because of the patient's small size, a super umbilical ring incision is used to place the V's needle, and then a 4 millimeter trochar for the camera port. Care is taken to avoid the umbilical vein during insertion, as this is, and so the trochar is just to the left of midline. After the right and left hand ports are placed, a full thickness biopsy is obtained from the muscular wall using sharp dissection. There was a clear transition zone at the. Between the distal sigmoid and the rectum, and the biopsy was obtained approximately 5 centimeters above this. While waiting for the frozen section to return, the mesenteric dissection is started. The key to this deception is staying exactly adjacent to the. Colon wall this prevents injury to any of the surrounding structures. Because all heat and energy remains between the jaws of the sealer. There is no danger in injuring any of these structures by. Brushing aside them with the sealer. As you can see, the small perforating vessels are simply grasped, sealed, and then pulled down off the Rectal wall. This is done circumferentially to gradually dissect down along the. A ganglionic portion of the colon. Dissection becomes a little bit more difficult. At the perineal reflection, but again, the same technique of simply grasping the peritoneal reflection in the small perforating vessels and then pulling them down off the colon to be removed. is a safe and well tested technique. The advantage of the 3 millimeter sealer is that you can not only Dissect off these vessels, but then dissect around the colon to mobilize the tissue. There is no risk of pass pointing as with a 3 millimeter hook, which used to be our preferred mode of deception. The other advantage is that there is no need to perform instrument changes with the right hand. Throughout the case, a bough grasper is placed. In the left hand to retract the sigmoid colon, and the sealer is the only instrument used in the right hand. Again, you can see how dissection stays right on the bow wall, ensuring that none of the surrounding structures are injured. The key is to carry this dissection down to the pelvic floor. This limits the amount of transanal dissection which is necessary and decreases the risk of any injury to the external sphincter. One can see that the view is excellent down into the pelvic floor and that the same method is used all the way down. Again, because there is no energy spread from the tips of the instrument, it is safe for the instrument to be adjacent to the bladder, the vagina, the prostate, and other surrounding structures. And again, because the energy is only between the jaws of the instrument, this diminishes the risk of injury to the ureters and other vital structures such as the vast ephrons and bus. Here you can see the section is almost down to the pelvic floor, and the final bands of tissue and inferior rectal vessels are sealed and separated from the colon without difficulty. When diagnosed, we prefer to perform this operation in the newborn period. But it is also acceptable if the child tolerates rectal irrigations to let them grow. However, with the current technology, we feel the operation is extremely safe in the newborn period, and we prefer to do the pull through prior to discharge to home. Here you can see the laparoscopic dissection completed, and now we are ensuring that there is adequate length of the colon immobilized to allow for the poultry. At this point we start the transanal dissection. The baby's legs are pulled up on the chest, and then a series of tracks and stitches are placed. Inside The anus just proximal to the dentate line and then out to the skin slightly inverting. The Anus so that the dentate line can be clearly visualized. Somewhere between 4 to 8 sutures are used to affect this. Then once the. Anus is averted. A mucosal incision is made with the Hand cautery. Just pro proximal to the. Dentate line and rip. This is usually 2 to 3 millimeters proximal to this point. Once this plane is developed, a series of traction or stay sutures are placed. In the mukosa To help retract The mucosa to allow for the submucosal deception. The key to this portion of the operation is that it should all take place externally to the anus. The beauty of the laparoscopic dissection down to the pelvic floor is that it allows release of this area so that the dissection can be carried out. Outside of the anus, so no retractors are ever placed within the external sphincter which may cause. These muscles to be damaged. You can see the white glisteny. Plane that represents the submucosal space. We prefer to use sharp dissection to mobilize this area, although blunt dissection can also be used. Small perforating vessels are identified and cauterized as seen. The section is carried around circumferentially until the muscular cuff reverts. At which point we will enter the peritoneal cavity. Again, you can see that the entire deception is taking place uh external to the anus and not up within, not within the canal. This again protects the External sphincter muscles. And improves the chance of good continence. If the right plane is achieved, the mucosa very easily diverts. Prior to dividing the cuff, a stitch is placed as a retractor so that the muscular cuff can be divided at the 6 o'clock position. And the dissection is carried circumferentially, allowing the colon to be pulled down through the anus. Here you can see our biopsy site, which is 5 to 6 centimeters above the obvious transition zone. There are some mesenteric attachments still present, and these are taken externally using the 3 millimeter sealer. Which allows greater mobilization of the colon and allows us to get a good 5 to 6 centimeters above the biopsy site. Where you can see the colon resting comfortably. We now go back in laparoscopically to ensure the proper orientation of the pull through and that there are no structures caught under the mesentery. The colon is then divided. Again, 5 to 6 centimeters above the biopsy site, which is 5 centimeters above the obvious transition zone, and then new coloranal anastomosis is performed. At the previously. Divided plain. 4 quadrant state sutures are placed. And the colon specimen is then excised. In general, we place. 3 to 4 additional sutures in each quadrant for a total of 12 to 16 sutures. Forming the new coloanal anastomos. These are done with oral viral suture in newborn. This operation took 70 minutes. The child was left without a nasogastric tube and started stooling the morning following surgery. The patient was then started on feeds that afternoon, less than 24 hours after the procedure. Once all the sutures are placed, they're cut, allowing the anus to then. Reinvert The Stay sutures are removed and then the anastomosis is calilibrated with a number 12 Haggard dilator. At the end of the procedure, we place a gauze packing in the anus.