V91 - Tips and tricks for laparoscopic modified Duhamel procedure

CME Eligible

Purpose/Background: Chagas disease is an endemic disorder in most Latin American countries. It is caused by the parasite Trypanosoma cruzi, which is transmitted by the bite of an insect known as the Vinchuca. Chagasic megacolon is a late complication resulting from the destruction of the autonomic intestinal nervous plexus, leading to an increase in both the diameter and length of the large bowel. This condition is associated with complications such as sigmoid volvulus, fecal impaction, and perforation.

Several surgical interventions have been developed to address the complications of Chagasic megacolon. The original description of Duhamel's procedure dates back to 1956, and it has undergone several modifications since then - from the introduction of mechanical staplers to the division of the colorectal septum to widen the anastomosis through a minimally invasive approach.

This is a scientific video presenting practical tips and tricks for performing laparoscopic modified Duhamel surgery for Chagasic megacolon.

Methods/Interventions: The goal of the procedure is to resect the megacolon and bring down the healthy proximal colon through a posterior rectal space, creating an anastomosis between the descended colon and the posterior wall of the rectum. Finally, the anastomosis is enlarged by dividing the remaining septum with a linear stapler.

Ports were placed as follows: one umbilical, one right subcostal, two in both flanks, and one accessory suprapubic trocar.

First, we performed a rectoscopy and advanced a suction tube to achieve adequate colonic decompression.

We began with a medial approach to the mesocolon, which was more demanding than usual due to the fusion of normal anatomical planes. The retroperitoneal structures were mobilized, and the left ureter was identified.

The inferior mesenteric vessels were divided, and we continued with the lateral approach to the mesocolon.

The mesorectal dissection was carried out from its posterior plane, creating a retrorectal tunnel of adequate size to allow the descended colon to pass through without tension, but not excessively wide, in order to avoid unnecessary pelvic dissection that could cause fluid accumulation or lymphovascular and nerve injury.

The distal rectal section was completed at the level of the peritoneal reflection.

We confirmed that the descended colon reached below the lower edge of the pubis to ensure a tension-free anastomosis.

During the perineal phase, the area was exposed using a Lone Star retractor, and the circular stapler was introduced upside down. The stapler was closed, ensuring no tissue was trapped, palpated to confirm correct positioning, and then fired.

Finally, a linear stapler was used to enlarge the anastomosis by dividing the remaining septum between the rectum and the descended colon.

Results/Outcomes: Postoperative recovery was uneventful. The patient was fit for discharge on the fifth postoperative day. The pathology report confirmed a megacolon with a hypoganglionic segment.

Conclusion/Discussion: The laparoscopic modified Duhamel procedure is a safe and feasible technique that offers the best functional outcomes, significant symptom relief and low complication rates.