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Use of a SILS(TM) port in transanal endoscopic surgery for the incomplete section after Duhamel-Martin procedure in a 10-year-old boy

Masashi Kurobe¹, Yuji Baba¹, Syuichi Ashizuka², Masahiko Otsuka¹
¹Department of Surgery, Kawaguchi Municipal Medical Center, Saitama, Japan
²Department of Surgery, Jikei University School of Medicine, Tokyo, Japan


Correspondence

Masashi Kurobe MD
Kawaguchi Municipal Medical Center
180 Nishi-Araijuku, Kawaguchi, Saitama Prefecture 333-0833, Japan
Tel: +81-48-287-2525
Fax: +81-48-280-1570
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


Abstract

Recently, the use of a single-incision laparoscopic surgery port (SILSTM port, Covidien) for transanal endoscopic microsurgery has been validated in the adult population, but not yet in children. We report the case of a 10-year-old boy with chronic anal bleeding from an incomplete section of the septum between rectum and pulled through segment with an endoscopic linear stapler after the Duhamel-Martin procedure for extensive aganglionosis. We performed a redo transection of the septum by transanal endoscopic surgery using the SILSTM port successfully. There was no fecal incontinence or soiling during the postoperative follow-up and anal bleeding didn’t relapse. To the best of our knowledge, this is the first report worldwide of initial experience with transanal single port surgery in pediatric population. Careful patient selection and further experience including long-time outcomes are needed to fully define the indication of this procedure in the pediatric population.

Key words: SILS port, transanal, Duhamel-Martin, endoscopic linear stapler

 

Introduction

Recently, the use of a single-incision laparoscopic surgery port (SILSTM port, Covidien) for transanal endoscopic microsurgery has been validated in the adult population, but yet not in children [1-3].

Case presentation

We report the case of a 10-year-old boy with chronic anal bleeding. He initially underwent Duhamel-Martin procedure with an endoscopic linear stapler for extensive aganglionosis at the age of 10 months. Colonoscopy confirmed that chronic bleeding was caused by an incomplete section of the septum between rectum and pulled through segment. There were 2 incomplete sections and the distance from the anal verge to each incomplete section was 5 cm and 13cm, respectively. We planned a redo transection of the septum by transanal endoscopic surgery using the SILSTM port. After general anesthesia, the patient was positioned in the lithotomy position. First, the proximal section could not be resected with the aid of the SILSTM port due to the small distance between the port and the section. The section was resected using an open transanal technique with the endoscopic linear stapler (EchelonTM Gold 60mm, Ethicon). Next, the SILSTM port was lubricated and gently inserted into the anal canal without prior dilatation (fig. 1).

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Figure 1. SILSTM port is introduced into the anal canal.

The bowel was expanded by continuous carbon dioxide insufflation up to 12 mm Hg. Two 5-mm trocars and one 12-mm trocar were introduced into the SILUse of a SILSTM port in transanal endoscopic surgery for the incomplete section after Duhamel-Martin procedure in a 10-year-old boy. A 5-mm atraumatic grasper and a 30 degree 5-mm flexible laparoscope were used via the 5-mm trocar and the 60-mm EchelonTM Gold was introduced into the rectum via the 12- mm trocar. With the manipulation of the 5-mm atraumatic grasper, we could visualize and the section was transected with the EchelonTM without bleeding from the stapler line (fig. 2). The patient was discharged on the next day. There was no fecal incontinence or soiling during the postoperative follow-up and no anal bleeding was noted.

JPSS december 2013 Page 13 Image 0002

Figure 2. SILSTM port is introduced into the anal canal.

Discussion

With the introduction of the endoscopic linear stapler, the 1-stage Duhamel-Martin procedure for Hirschsprung’s disease became feasible for neonates and infants [4]. Yanagihara et al. [5] reported that they sometimes faced the problem of bridge formation from staplers in the side-to-side anastomosis using a 50-mm linear stapler and the 80-mm linear stapler solved this problem. According to the surgical record of the recent patient’s initial operation, a 60-mm endoscopic linear stapler was used to make the side-to-side anastomosis. In their follow-up study, Mattioli et al. [6]. reported that 3 of 56 patients developed chronic bleeding caused by an incomplete section of the septum between rectum and pulled through segment leaving artery on the tip of the side-to-side anastomosis. This artery caused granulation of the septum with subsequent bleeding. A redo transection of the septum was required in 1 of 3 patients, but how they did it was not reported.

Transanal endoscopic microsurgery (TEM) system has emerged as an important method of anorectal surgery in adults. However, the need for specific training and the high cost of specialized instrumentation may lead the slowly gained widespread acceptance in anorectal surgery. Also, there is a disturbed anorectal function observed after TEM [7,8].

Recently, several case reports have been published utilizing the SILSTM port for transanal access in adult population, such as resection of benign polyps, excision of early cancers of rectum, and removal of foreign body [1-3]. The SILSTM port is 3 cm in diameter at its neck and contains three 5-mm cannulas for single-port surgery and a separate insufflations-dedicated access. The port is also designed so that one of the 5-mm cannulas can be exchanged for a 12-mm cannula.

The advantages of the SILSTM port compared with TEM system are numerous. The most important issue is its smaller size and sponge-like material, which should be less damaging to the anorectal function. A flexible and soft shape of the SILSTM port is also ideal for placement into the anal canal and in our experience has provided a confirming fit to the anus without leak age of insufflated CO2 and can be removed quickly and reintroduced as needed. Furthermore, normal laparoscopic instruments and energy devices can be used and we do not require special training, thus the SILSTM port system is relatively inexpensive.

One of the limitations for transanal procedure using the SILSTM port appears to be the distance to the anal verge. In our patient, the proximal section (5cm from anal verge) could not be resected with the aid of the SILSTM port due to the small distance between the port and the section. The section was resected easily using an open transanal technique with the endoscopic linear stapler. Van den Boezem et al [3]. reported that a minimum distance should be 3 cm and the open resection was not technically difficult in less than 3cm cases.

Other limitation in children should be the size of anal canal. In the recent case, patient’s body weight and height were 22kg and 130cm, respectively. As with the reported cases in adults, there was no fecal incontinence or soiling during the postoperative follow-up in our patient, however, even though the SILSTM port is smaller and softer than TEM system, it may damage the rectal function, if used for the smaller children.

In summary, using a SILSTM port, we could have visualization and transanal endoscopic surgery was performed successfully. To the best of our knowledge, this is the first report worldwide of initial experience with transanal single port surgery in pediatric population. Careful patient selection and further experience including long-time outcomes are needed to fully define the indication of this procedure in the pediatric population.

Acknowledgments

We thank Rupert Burrows for correction and translation.

 

 

 

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