214 Duhamel – how minimally invasive can you be?
Zeni Haveliwala, Nordeen Bouhadiba
Evelina Children's Hospital, London, United Kingdom

Abstract

Aim

Over the recent 20 years there have been a variety of modifications to the Duhamel pull-through, adapted for the use of laparoscopy.  Many of these modifications have altered the technique in such way that the basic principles of the original procedure are no longer respected.  

 

Reports of laparoscopic-assisted Duhamel describe eversion of the rectum to allow closure of the rectal stump.  This involves dissection of the rectum to the pelvic floor, division of the Denoviller’s fascia and consequent injury to the nerve erigentes and vascular structures. 

 

We describe a new laparoscopic Duhamel technique strictly adhering to the original principles with preservation of Denovillier’s fascia.

 

Method

5 patients with Hirschsprung’s disease underwent laparoscopic Duhamel pull-through.  The procedure is described as follows.

 

Two 10mm ports are placed supra-umbilically and in the right flank.  A further 5mm port is placed in the left flank.  Pneumoperitoneum is established and mapping biopsies are taken.  The distal large bowel is mobilised as necessary.  The rectum is then circumferentially detached from its peritoneal attachments and posterior rectal space is developed.  With cranial traction on the sigmoid colon the rectum is divided just below the peritoneal reflection using a 45mm articulating endo-GIA stapler.  The right flank port is removed for this manoeuvre to ease stapler articulation.  The mobilised colon is then pulled through in the posterior rectal space, with subsequent anastomosis to the ganglionic bowel using an endo-GIA stapler from the anal canal. 

 

Results

The post-operative course was unremarkable, with no spur or anastomotic leak.  There was an adequate rectal stump.

 

Conclusion

We present new technique of the laparoscopic Duhamel procedure adhering to the original description.


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