Transanal Mesenteric Resection in Hirschsprung's Disease Using ICG under Concept of NOTES Technique.

Laparoscopic surgery has been applied for Hirschsprung's disease (HD). We herein report our approach to mesenteric processing for laparoscopic-assisted transanal endorectal pull-through (L-TERPT). Following mucosectomy and entering the abdominal cavity, a vessel sealing system is transanally inserted into the abdominal cavity for mesenteric processing based on concept of Natural Orifice Translumenal Endoscopic Surgery. Since the transanal axis is parallel to the dissected mesentery, it makes easier to operate in comparison to when the procedure is performed through the abdominal working port and can reduce the additional abdominal trocar wound. We also use indocyanine green (ICG) fluorescence navigation. Fluorescing the vessels with ICG allows intraoperative visualization of the blood flow in the retrieved intestine. With these innovative combined techniques, L-TERPT for HD can be safely performed, even in infants with small intraabdominal cavities.