Transanal Approach

More recently, De La Torre and Ortega12 created a simple but ingenious and original way to treat this condition. They demonstrated first in animals and then in humans that the rectosig-moid can be resected in a purely transanal fashion. The resection is performed and the aganglionic segment is simultaneously pulled down through the anus. Interestingly, in the most common type of Hirschsprung's disease (the so-called classic type), the entire agan-glionic segment can be transanally resected and the normoganglionic colon can be anastomosed to the anal canal transanally, avoiding any kind of laparotomy or laparoscopy. Fortunately, the so-called classic form of Hirschsprung's represents approximately 80% of the cases, which gives extra value to this ingenious technique. The transanal approach has been rapidly adopted, and larger series of cases have been reported.66,67 The patient is placed in lithotomy position or alternatively can be placed in a prone position with the pelvis elevated.A special retractor (Lone Star, Houston, Texas) is used to expose the anal canal (Fig. 24.4A). The great advantage of this

Figure 24.4. Transanal technique (De La Torre).a:"Lone star" retractor exposing the rectal mucosa and pectinate line. b: Multiple silk sutures lifting the rectal mucosa above the pectinate line. c: Full-thickness dissection of the rectum after the peritoneal reflection and beyond. d: Anastomosis of normal ganglionic bowel to the rectum 1 cm above the pectinate line.

Figure 24.4. Transanal technique (De La Torre).a:"Lone star" retractor exposing the rectal mucosa and pectinate line. b: Multiple silk sutures lifting the rectal mucosa above the pectinate line. c: Full-thickness dissection of the rectum after the peritoneal reflection and beyond. d: Anastomosis of normal ganglionic bowel to the rectum 1 cm above the pectinate line.

Figure 24.4. Continued

Figure 24.4. Continued retractor is that it can dilate the anus in a symmetric circumferential fashion to very clearly expose the anal canal. Multiple 6-0 silk sutures are placed, incorporating the rectal mucosa above the anal canal in order to exert the uniform traction that is very important to perform an efficient and neat dissection of the rectum above the pectinate line (Fig. 24.4B). The original De La Torre technique is an endorectal technique performed from below. At our institution, we have been using a transanal full-thickness dissection, or a transanal Swenson procedure. Both ways are equally successful and can be done depending on the experience of the operator. While applying uniform traction to the multiple 6-0 sutures, a circumferential dissection is performed either submucosally or full-thickness, dividing and cauterizing the extrinsic blood supply of the rectum. By performing this procedure,length is gained in the dissection and, surprisingly, the peritoneal reflection can be reached very rapidly (Fig. 24.4C). As the dissection progresses, one can take full-thickness biopsies.

We advise taking full-thickness biopsies every 4 cm during this dissection. The dissection must continue until the normoganglionic bowel is reached. If, at that point, the surgeon perceives that the colon is already normoganglionic but very dilated, it is mandatory to continue the dissection until normoganglionic and nondilated colon is reached. One can usually dissect and resect comfortably and safely the rectosigmoid up to the junction of the sigmoid with the descending colon. Endeavoring to go higher than that, even when feasible, makes the procedure rather risky and uncomfortable. At that point, one can continue laparoscopically or by laparotomy.

We routinely perform an end-to-end anastomosis with two layers of interrupted 6-0 long-term absorbable sutures between the nor-moganglionic, nondistended portion of the colon and the anal canal (Fig. 24.4D). The patient receives parenteral nutrition, and oral feeding is initiated 2 to 4 days after the operation.

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