Laparoscopic Operation

  • Atsuyuki YamatakaEmail author
  • Masahiro Takeda
  • Go Miyano


During transanal pull-through (TAPT) for Hirschsprung’s disease (HD), transanal dissection should commence just proximal to the anorectal line (ARL), leaving the ARL intact and preserving the anal transitional zone (ATZ), to ensure good postoperative bowel function (POBF). The ARL is a readily identifiable landmark, and transanal dissection will thus be performed identically by all surgeons with reliable and reproducible results. The posterior rectal muscle cuff above the ARL should be excised completely to fully release achalasia while preserving the ARL and the ATZ.

In contrast, when the dentate line (DL) is used, transanal dissection may commence anywhere from 5 to 20 mm above the DL depending on the surgeon’s preference, and outcomes may vary or even be unpredictable because dissection may commence too far from the DL (i.e., above the ARL) and cause constipation, or the ATZ may be injured because dissection may commence too close to the DL (i.e., below the ARL) and cause fecal incontinence.

TAPT has benefitted from the incorporation of minimally invasive surgical techniques. In particular, laparoscopy-assisted TAPT (L-TAPT) has significant advantages; the presence of ganglion cells can be verified in the proximal bowel segment using laparoscopy-assisted colon suction biopsy, torsion during colonic pull-through can be prevented, blood supply to the distal end of the pull-through colon can be fully preserved, and tension on the vascular arcade of the pull-through colon can be excluded.

From experience, using L-TAPT with the ARL as the landmark for transanal dissection will result in favorable predictable POBF without risk for inadequate pull-through of aganglionic bowel.


Laparoscopy Transanal pull-through Anorectal line Dentate line Anal transitional zone Rectal muscle cuff 


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© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  1. 1.Department of Pediatric SurgeryJuntendo University School of MedicineTokyoJapan

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