Technique of Laparoscopic Swenson Procedure for Short Segment Hirschsprung's Disease

Abstract

Background:

Several previous reports have demonstrated that the laparoscopic Swenson technique is a viable alternative to the open procedure and that it has several advantages, including shorter length of hospital stay, earlier return of bowel function, and, most importantly, fewer complications. ^{1 –3}

Aim:

A video demonstrating the technique of laparoscopic Swenson procedure.

Case Report:

A 6-month-old infant presents as a neonate with abdominal distention and failure to pass meconium. Rectal suction biopsies demonstrate evidence of Hirschsprung's disease, and further laparoscopic biopsies confirm short segment involvement. A primary laparoscopic Swenson procedure is performed at 6 months of age.

Technique:

A 4-port approach using a 10-mm umbilical port and three 5-mm ports (umbilical & right & left iliac fossa) are utilized. Intra-abdominal insufflation pressure is maintained at 10 mmHg. Once pneumoperitoneum is established, a 2-0 silk stay is passed through the anterior abdominal wall and the bladder fundus to allow adequate observation of the pelvic structures. Initially, posterior mobilization of the rectum is performed using hook diathermy and a posterior window is created which allows exploitation of the presacral plane. Further, dissection of the lateral and anterior aspects of the rectum is performed, taking care to observe and preserve both ureters and vas deferens. Dissection continues in an incremental fashion anteriorly and laterally down to the pelvic floor. The correct level of distal mobilization is ascertained with the assistance of a second surgeon applying perineal pressure. A harmonic scalpel is applied to ligate the mesenteric vessels and an Endo-GIA 5-mm stapler used to transect the sigmoid colon at the level of the ganglionated bowel. A second surgeon working from below assists in grasping and invaginating the distal aganglionic colorectal stump. An incision is made in the externalized colorectum ∼1 cm proximal to the dentate line and forceps passed through this incision to grasp the distal margin of the ganglionated bowel, which is delivered to the peritoneum. A full-thickness circumferential anastomosis to the invaginated rectum is then completed extracorporeally in conventional fashion.

Results:

Enteral diet is introduced on day 1 and discharge occurs on day 4. There are no intra- or postoperative complications, and at follow-up 17 months later the child remains well.

Conclusion:

The case highlights the technical aspects of a laparoscopic Swenson procedure. Advantages include excellent observation of the pelvic structures, safe dissection of the ureters, and vas and avoidance of injury to pelvic nerves. Medium-term follow-up is encouraging; however, long-term performance particularly relating to erectile and bowel function is yet to be established.

No competing financial interests exist.

Runtime of video: 5 mins