Tim J. Bradnock

Laparoscopic assistance for primary transanal pull-through in Hirschsprung's disease: a systematic review and meta-analysis.

Objective To compare outcomes following totally transanal endorectal pull-through (TTERPT) versus pull-through with any form of laparoscopic assistance (LAPT) for infants with uncomplicated Hirschsprungs disease. Design Systematic review and meta-analysis. Setting Five hospitals with a paediatric surgical service. Participants 405 infants with uncomplicated Hirschsprungs disease. Interventions TTERPT versus LAPT. Primary and secondary outcome measures Primary outcomes: mortality, postoperative enterocolitis, faecal incontinence, constipation, unplanned laparotomy or stoma formation, and injury to abdominal viscera. Secondary outcomes Haemorrhage requiring transfusion of blood products, abscess formation, intestinal obstruction, intestinal ischaemia, enteric fistula formation, urinary incontinence or retention, impotency and duration of procedure. Results Five eligible studies comprising 405 patients were identified from 2107 studies. All studies were retrospective case series, with variability in outcome assessment quality and length of follow-up. Operative duration was 50.29 min shorter with TTERPT (95% CI 39.83 to 60.74, p<0.00001). There were no significant differences identified between TTERPT and LAPT for incidence of postoperative enterocolitis (OR=0.78, 95% CI 0.44 to 1.38, p=0.39), faecal incontinence (OR=0.44, 95% CI 0.09 to 2.20, p=0.32) or constipation (OR=0.84, 95% CI 0.32 to 2.17, p=0.71). Conclusions This meta-analysis did not find any evidence to suggest a higher rate of enterocolitis, incontinence or constipation following TTERPT compared with LAPT. Further long-term comparative studies and multicentre data pooling are needed to determine whether a purely transanal approach offers any advantages over a laparoscopically assisted approach to rectosigmoid Hirschsprungs disease. Trial registration number PROSPERO registry- CRD42013005698.

Urogenital anomalies in girls with sacrococcygeal teratoma: a commonly missed association

BACKGROUND The association of urogenital (UG) anomalies and sacrococcygeal teratoma (SCT) has not been widely reported. Our aim was to look at the national incidence and presentation of this anomaly in patients with SCT and to provide the first report of a clear anatomical description of this commonly missed association. METHODS Sacrococcygeal teratoma cases in Scotland during the last 30 years were identified. Patients with associated UG anomalies were reviewed in detail to identify their presentation, anatomy, and management. RESULTS Fifty-three patients with SCT were identified, including 41 girls. Five girls (12%) subsequently had a UG anomaly diagnosed, which was not apparent at the initial surgery. Two patients presented with retention, and their anomaly was diagnosed at 6 weeks and 7 months of age. The other 3 presented with incontinence, and despite thorough assessment, including cystoscopy, their UG anomalies were not recognized until the ages of 7, 9, and 13 years. CONCLUSIONS Urogenital anomalies are surprisingly common in girls with SCT. The reason for this association is unclear. None of these cases were diagnosed initially, which means that it was either missed or acquired. Urogenital anomalies should be suspected in girls with SCT and actively excluded in those with voiding difficulties.

E37 Open Duhamel Pull-Through

This operation was devised to avoid the difficult peri-rectal dissection of the Swenson procedure, whilst minimising the risk of damaging the nervi erigenti, that course laterally and anteriorly over the rectum. Duhamel proposed a retrorectal dissection without resection of the rectum as a means to achieving this. The rectal reservoir created has an anterior aganglionic wall and a posterior ganglionic wall (Fig. 1). Duhamel’s original operative procedure was later modified with the use of a linear stapling device to create the rectal reservoir instead of Kocher clamps, which previously were left in situ for 5–10 days. The Duhamel procedure can also be performed with laparoscopic assistance either as a primary or staged procedure.

E34 Open Endorectal (Soave-Boley) Pull-Through

This operation is increasingly being performed using laparoscopic-assisted transanal (see Chap. I16, Laparoscopic Splenectomy’) or purely transanal approaches (see Chap. E33, Transanal Endorectal Pull-Through for Rectosigmoid Hirschsprung Disease’). In the ‘open’ method, endorectal dissection can be carried out from the abdominal approach, or transanally.

A12 Gridiron, Lanz and Rutherford Morison Incisions

The gridiron and lanz incisions are muscle-splitting incisions which are the incisions of choice for open appendicectomy. They differ in the orientation of the skin incision alone. The gridiron incision can be more readily extended laterally into an oblique, curvilinear muscle-cutting incision: the Rutherford Morison.

I14 Primary laparoscopic-assisted endorectal pull-through

Single stage pull-through for Hirschsprung’s Disease has gained in popularity since its introduction in 1980 and is suitable for left-sided disease where colonic decompression can be achieved with rectal washouts. A defunctioning stoma may be required if adequate decompression is not achieved, in cases of severe enterocolitis, perforation or long-segment aganglionosis.

H3 Perianal Abscess and Fistula-in-Ano

Place the patient in the lithotomy position. Prepare the skin with aqueous Betadine. Examine the perianal region for induration, skin tags or fissures (Figs. 1 and 5). Perform a digital rectal examination. Perform proctoscopy to exclude an internal fistulous opening (see Chap. E3). Palpate the swelling and use a scalpel to make a cruciate incision over the point of maximal fluctuance (Fig. 2).

I26 Laparoscopic-Assisted Insertion of a Peritoneal Dialysis Catheter

Peritoneal dialysis is an alternative to haemodialysis and is used to treat patients with end-stage renal disease. Different techniques have been developed for catheter placement. We describe a single-port laparoscopic technique which allows good visualization of the pelvis and accurate positioning of the peritoneal catheter, with a low complication rate and excellent cosmetic result.

E32 Rectal Biopsy

Administer prophylactic antibiotics. Ensure that vitamin K given to neonates. Ensure pathologist available; the biopsy must be sent fresh. The procedure can be performed without general anaesthetic. Neonates should be placed in the lithotomy position. Older children should be placed on the left lateral side, knees bent. Anatomy of suction biopsy forceps (Fig. 1) Blunt, hollow tube, side hole 1 cm from tip Concealed blade within shaft of instrument Marks on side of tube show level of biopsy Side port for attaching suction tubing 5- to 20-ml syringe to apply suction Variation Disposable capsules and blade (Fig. 2) In-line manometer to record suction

A10 Subcostal and Rooftop Incisions

A standard subcostal incision can be extended with a curve across the midline to make a rooftop (bilateral subcostal) incision (Fig. 1). The Mercedes-Benz modification involves a further extension to the rooftop incision, with an upper midline limb extending up to or through the xiphisternum (Fig. 1, dotted line).