Totally robotic soave pull-through procedure for Hirschsprung's disease: lessons learned from 11 consecutive pediatric patients

Robotic-assisted Proctosigmoidectomy Versus Laparoscopic-assisted Soave Pull-through for Hirschsprung Disease: Medium-term Outcomes From a Prospective Multicenter Study

OBJECTIVE

To compare the surgical outcomes of robotic-assisted proctosigmoidectomy (RAP) and laparoscopic-assisted Soave pull-through (LAP) for children with Hirschsprung disease (HD).

BACKGROUND

LAP and RAP have been developed for minimally invasive pull-through of HD, but the clinical benefits of robotic-assisted versus laparoscopic-assisted approaches have yet to be proven in a multicenter prospective study.

METHODS

This study was a prospective multicenter clinical trial conducted on children with rectosigmoid/descending HD from July 2015 to June 2022, with registration in the Chinese Clinical Trial Registry (ChiCTR2000035220). The primary outcome was the medium-term functional outcomes in children aged ≥4 years based on bowel functional scores, which were assessed and compared between LAP and RAP.

RESULTS

A total of 328 consecutive patients (RAP = 165, LAP = 163) were approached who were considered eligible for elective minimally invasive endorectal pull-through, and 219 patients aged ≥4 years of age completed follow-up (RAP = 109, LAP = 110). The transanal dissection length and anal traction time were significantly shorter in RAP than those in LAP (0.40 vs 3.70 cm, P < 0.001; 45 vs 62 min, P < 0.001). The RAP group had a significantly lower urinary retention rate (0% vs 5.52%, P = 0.006), whereas other short-term results between the two groups were not significantly different. The medium-term overall bowel function scores were comparable between the two groups; however, among the subgroup of children aged ≤3 months at surgery, the RAP group had better anal canal resting pressure at 1 year postoperatively and amounted to better annual postoperative fecal continence scores at 4 to 7 years old postoperatively (all P < 0.05).

CONCLUSIONS

RAP and LAP should have similar medium-term bowel functional outcomes in children with HD, but RAP may be associated with a slight functional benefit in infants operated on below age 3 months, requiring further investigation in larger case cohorts.

Advancing Pediatric Robotic Colorectal Surgery: Trends, Outcomes, and Future Directions-A Comprehensive Review

INTRODUCTION

 Pediatric robotic colorectal surgery has rapidly evolved, offering enhanced precision and safety for treating complex conditions such as Hirschsprung disease (HSCR), anorectal malformations (ARMs), and inflammatory bowel disease (IBD). This review analyzes recent trends, outcomes, and complications in robotic colorectal procedures for pediatric patients.

MATERIALS AND METHODS

 A systematic review was performed using PubMed, yielding 1,112 articles related to pediatric robotic colorectal surgery. After applying exclusion criteria, 35 papers were analyzed, focusing on patient characteristics, procedure types, and clinical outcomes.

RESULTS

 Since 2001, approximately 700 pediatric patients have undergone robotic colorectal procedures, with HSCR being the most commonly treated condition (n = 421). The review highlights that 1.7% of patients experienced Clavien-Dindo grade III complications, while 11.5% had grade I to II complications, indicating a favorable safety profile. The use of robotic platforms facilitated improved precision during perirectal dissection and reduced the risk of damage to adjacent structures, particularly in cases requiring complex pelvic dissections. Despite promising outcomes, the uptake of robotic colorectal surgery remains lower than that for urologic procedures due to challenges such as cost, instrument size, and specialized training.

CONCLUSION

 Robotic colorectal surgery in children is a safe and effective approach, particularly for complex conditions like HSCR, IBDs, and ARMs. While adoption is currently limited by cost and training requirements, ongoing advancements in technology and techniques promise to broaden its application and improve outcomes in pediatric surgery.

Comparison of robot-assisted and laparoscopic-assisted modified Soave short muscle cuff anastomosis surgeries for classical Hirschsprung disease

BACKGROUND

In this study, we aimed to compare the efficacy of robot-assisted and laparoscopic-assisted modified Soave with that of short muscular cuff anastomosis surgery for classical Hirschsprung disease (HSCR).

METHODS

Sixty children with HSCR who underwent surgical treatment in our department between January 2021 and December 2023 were retrospectively enrolled. The collected data included operative time, anal dissection time, blood loss, length of hospital stay, postoperative complications, and postoperative defecation control status.

RESULTS

No significant differences were observed in the operative time between the robot and laparoscopic groups (P > 0.05); however, the anal dissection time and intraoperative blood loss in the robot group were significantly lower than those in the laparoscopic group (P < 0.05). Additionally, there was no significant difference in the incidence of enterocolitis and length of hospital stay between the two groups. Significantly more patients presented with anastomotic complications in the laparoscopic group than in the robot group (P < 0.05). The defecation and soiling frequencies in the robot group were significantly lower than those in the laparoscopic group at the follow-up examination (P < 0.05). The postoperative defecation function score in the robot group was better than that in the laparoscopic group (P < 0.05).

CONCLUSION

Robot-assisted modified Soave with short muscular cuff anastomosis has a shorter anal dissection time, lower incidence of anastomotic complications, and better defecation function in patients with classical Hirschsprung disease.

LEVEL OF EVIDENCE III

Post-surgical Outcomes of Different Surgical Techniques in Hirschsprung's Disease: A Literature Review

Hirschsprung's disease (HD) is a rare condition that affects newborns and is characterized by the lack of ganglion cells in the colon. Typical symptoms include difficulty passing stool, vomiting, and trouble feeding. Various surgical methods are available to manage the condition. The aim of the study is to investigate and compare the post-surgical outcomes of different surgical techniques used in the treatment of HD. A thorough literature search was conducted using various electronic databases to identify relevant studies to be referred to. Double-blinded screening of the identified articles led to the final selection of 40 out of 440 HD, including transanal endorectal pull-through (TERPT), laparoscopic approaches, and modified techniques. Several studies have investigated surgical procedures for HD, including TERPT, laparoscopic methods, and modified techniques. These have shown positive outcomes, with fewer complications, improved bowel function, and favorable cosmetic results. Individual patient characteristics and surgeon expertise should guide procedure selection. Surgery for HD aims to restore normal bowel function, but post-surgical outcomes can include constipation or fecal incontinence. Complications like enterocolitis, anastomotic stricture, and sphincter damage may occur. Laparoscopic approaches have shorter hospital stays. However long-term follow-up is essential to assess quality of life, psychological well-being, and potential side effects.

Comparation of robotic-assisted surgery and laparoscopic‑assisted surgery in children with Hirschsprung's disease: a single-centered retrospective study

BACKGROUND

There are few studies comparing robotic-assisted surgery (RAS) and laparoscopic-assisted surgery (LAS) in Hirschsprung's disease (HSCR). This study aimed to compare intraoperative and postoperative outcomes between RAS and LAS performed during the same period.

METHODS

All consecutive 75 patients with pathologically diagnosed as HSCR who underwent Swenson pull-through surgery from April 2020 to Nov 2022, were included. Patients were divided into RAS group and LAS group and a retrospective analysis was performed based on clinical indexes and prognosis.

RESULTS

A total of 75 patients were included, among which, 31 patients received RAS and 44 received LAS. The RAS and LAS groups had similar ages, sex, weight, postoperative hospital stays, and fasting times. Compared with LAS, blood loss (p = 0.002) and the incidence of Hirschsprung-associated enterocolitis (p = 0.046) were significantly lower in the RAS group. The first onset of Hirschsprung-associated enterocolitis in patients younger than 3 months occurred significantly earlier (p = 0.043). Two patients experienced anastomotic leakage in the LAS group and one patient experienced incisional hernia in the RAS group. The cost of RAS was significantly higher than that of LAS (p < 0.0001).

CONCLUSIONS

RAS is a safe and effective alternative for HSCR children, and a delaying primary surgery until later in infancy (> 3 months) may improve outcomes.

Paediatric robotic surgery: a narrative review

The benefits of minimally invasive surgery (MIS) compared with traditional open surgery, including reduced postoperative pain and a reduced length of stay, are well recognised. A significant barrier for MIS in paediatric populations has been the technical challenge posed by laparoscopic surgery in small working spaces, where rigid instruments and restrictive working angles act as barriers to safe dissection. Thus, open surgery remains commonplace in paediatrics, particularly for complex major surgery and for surgical oncology. Robotic surgical platforms have been designed to overcome the limitations of laparoscopic surgery by offering a stable 3-dimensional view, improved ergonomics and greater range of motion. Such advantages may be particularly beneficial in paediatric surgery by empowering the surgeon to perform MIS in the smaller working spaces found in children, particularly in cases that may demand intracorporeal suturing and anastomosis. However, some reservations have been raised regarding the utilisation of robotic platforms in children, including elevated cost, an increased operative time and a lack of dedicated paediatric equipment. This article aims to review the current role of robotics within the field of paediatric surgery.

Robotic-assisted proctosigmoidectomy for Hirschsprung’s disease: A multicenter prospective study

BACKGROUND

Robotic surgery is a cutting-edge minimally invasive technique that overcomes many shortcomings of laparoscopic techniques, yet few studies have evaluated the use of robotic surgery to treat Hirschsprung’s disease (HSCR).

AIM

To analyze the feasibility and medium-term outcomes of robotic-assisted proctosigmoidectomy (RAPS) with sphincter- and nerve-sparing surgery in HSCR patients.

METHODS

From July 2015 to January 2022, 156 rectosigmoid HSCR patients were enrolled in this multicenter prospective study. Their sphincters and nerves were spared by dissecting the rectum completely from the pelvic cavity outside the longitudinal muscle of the rectum and then performing transanal Soave pull-through procedures. Surgical outcomes and continence function were analyzed.

RESULTS

No conversions or intraoperative complications occurred. The median age at surgery was 9.50 months, and the length of the removed bowel was 15.50 ± 5.23 cm. The total operation time, console time, and anal traction time were 155.22 ± 16.77, 58.01 ± 7.71, and 45.28 ± 8.15 min. There were 25 complications within 30 d and 48 post-30-d complications. For children aged ≥ 4 years, the bowel function score (BFS) was 17.32 ± 2.63, and 90.91% of patients showed moderate-to-good bowel function. The postoperative fecal continence (POFC) score was 10.95 ± 1.04 at 4 years of age, 11.48 ± 0.72 at 5 years of age, and 11.94 ± 0.81 at 6 years of age, showing a promising annual trend. There were no significant differences in postoperative complications, BFS, and POFC scores related to age at surgery being ≤ 3 mo or > 3 mo.

CONCLUSION

RAPS is a safe and effective alternative for treating HSCR in children of all ages; it offers the advantage of further minimizing damage to sphincters and perirectal nerves and thus providing better continence function.

Pediatric colorectal robotic surgery

Robotic colorectal surgery allows adult and pediatric surgeons to overcome the technical limitations of laparoscopic surgery. It also provides improved ergonomics in the field of surgery. Robotic surgery has several advantages in colorectal operations that require complex minimally invasive skills including anorectal malformations, Hirschsprung disease, and inflammatory bowel disease. In this section, we discuss the key aspects of colorectal surgery where robotic instrumentation seems ideal.

Application and prospects of robotic surgery in children: a scoping review

As an innovative minimally invasive surgical technology, robot-assisted surgery (RAS) has greatly improved the accuracy and safety of surgery through the advantages of three-dimensional magnification, tremor filtering, precision and flexibility, and has been carried out by an increasing number of surgeries. In recent years, robots have been gradually applied to children, bringing new ideas and challenges to pediatric surgeons. This review will describe the advantages and limitations of robotic surgery in children, summarize its application in pediatric surgery, and provide an outlook. It is believed that clinicians should actively carry out RAS under the premise of rigorously ensuring surgical indications and strive to improve the efficacy of surgical treatment for children.

Surgical Management of Hirschsprung's Disease: A Comparative Study Between Conventional Laparoscopic Surgery, Transumbilical Single-Site Laparoscopic Surgery, and Robotic Surgery

Background

Hirschsprung's disease (HD) is a commonly digestive malformation in children that usually requires surgery. This study aims to evaluate the short-term efficacy of conventional laparoscopic surgery (CLS), transumbilical single-hole laparoscopic surgery (TU-LESS), and robotic surgery (RS) in the treatment of Hirschsprung's disease.

Methods

90 patients with Hirschsprung's disease undergone laparoscopic surgery at our center between 2015 and 2019, divided into three groups (group CLS, TU-LESS and RS), were retrospectively analysed.

Results

CLS and TU-LESS group showed no significant difference in operation duration (P &gt; 0.05) but shorter operation duration than the RS group (P &lt; 0.05). RS group had highest overall SCAR scores, while TU-LESS group had the lowest one (P &lt; 0.05). Other parameters such as operative blood loss, hospital stays, recovery time of digestive function, postoperative complications had no significant difference among the three groups (P &gt; 0.05).

Conclusion

The three surgical methods for HD revealed similar efficacy, where TU-LESS and CLS spent less time than RS; TU-LESS led to the most aesthetic effect, followed by CLS and RS.

Robotically Assisted Surgery in Children—A Perspective

The introduction of robotically assisted surgery was a milestone for minimally invasive surgery in the 21st century. Currently, there are two CE-approved robotically assisted surgery systems for use and development in pediatrics. Specifically, tremor filtration and optimal visualization are approaches which can have enormous benefits for procedures in small bodies. Robotically assisted surgery in children might have advantages compared to laparoscopic or open approaches. This review focuses on the research literature regarding robotically assisted surgery that has been published within the past decade. A literature search was conducted to identify studies comparing robotically assisted surgery with laparoscopic and open approaches. While reported applications in urology were the most cited, three other fields (gynecology, general surgery, and “others”) were also identified. In total, 36 of the publications reviewed suggested that robotically assisted surgery was a good alternative for pediatric procedures. After several years of experience of this surgery, a strong learning curve was evident in the literature. However, some authors have highlighted limitations, such as high cost and a limited spectrum of small-sized instruments. The recent introduction of reusable 3 mm instruments to the market might help to overcome these limitations. In the future, it can be anticipated that there will be a broader range of applications for robotically assisted surgery in selected pediatric surgeries, especially as surgical skills continue to improve and further system innovations emerge.

Robotic Soave pull-through procedure for Hirschsprung's disease in children under 12-months: long-term outcomes

PURPOSE

To describe the long-term outcomes of the robotic Soave pull-through (RSPT) procedure for Hirschsprung's disease (HSCR) in children younger than 12 months.

METHODS

A prospective observational study was conducted on HSCR patients under 12 months of age who underwent RSPT at our institution between 2011 and 2020. Data regarding demographics, clinical features, technical details, operative time, hospital stay, postoperative complications, and long-term outcomes were prospectively collected.

RESULTS

A total of 15 patients (9 male; 6 female) were included, with a median age at surgery of 4 months (interquartile range 3-6), and a mean weight of 6.8 ± 1.3 kg. Twelve patients suffered from rectosigmoid aganglionosis and three from long HSCR (extending up to the hepatic flexure). The mean total operative time was 240 ± 72 min. The median hospital stay was 3 days (interquartile range 3-4). Partial anastomosis dehiscence was observed in one patient, requiring reoperation on the 4th postoperative day. With a median follow-up of 79 months (interquartile range 45-115), no fecal incontinence or mild soiling were observed. Constipation occurred in two patients and mild enterocolitis in one case.

CONCLUSION

RSPT procedure for Hirschsprung's disease in children younger than 12 months is a safe and effective procedure, with few complications and satisfactory long-term continence outcomes.

Robotic-Assisted Minimally Invasive Surgery in Children

Currently, minimally invasive surgery (MIS) includes conventional laparo-thoracoscopic surgery and robot-assisted surgery (RAS) or robotic surgery. Robotic surgery is performed with robotic devices, for example the Da Vinci system from Intuitive Surgical, which has a miniaturized camera capable of image magnification, a three-dimensional image of the surgical field, and the instruments are articulated with 7 degrees of freedom of movement, and the surgeon operates in a sitting position at a surgical console near the patient. Robotic surgery has gained an enormous surge in use on adults, but it has been slowly accepted for children, although it offers important advantages in complex surgeries. The areas of application of robotic surgery in the pediatric population include urological, general surgery, thoracic, oncological, and otorhinolaryngology, the largest application has been in urological surgery. There is evidence that robotic surgery in children is safe and it is important to offer its benefits. Intraoperative complications are rare, and the frequency of postoperative complications ranges from 0–15%. Recommendations for the implementation of a pediatric robotic surgery program are included. The future will be fascinating with upcoming advancements in robotic surgical systems, the use of artificial intelligence, and digital surgery.

Minimally Invasive Redo Pull-Throughs in Hirschsprung Disease

Introduction: To reoperate a patient with Hirschsprung disease (HSCR) can be technically demanding and most surgeons would resort to conventional laparotomy. This article describes a series of patients with postoperative obstructive symptoms who underwent minimally invasive redo pull-throughs (MIRPT) (either laparoscopic or robotic) to assess the role of minimally invasive surgery (MIS) in complicated HSCR patients. Patients and Methods: All consecutive HSCR patients with postoperative obstructive symptoms, who underwent MIRPT with fast track concepts of care between January 2012 and January 2020, have been included. Data regarding indications, surgical details, complications, and outcome have been compared to those of a series of patients who underwent conventional laparotomic redo. Results: Sixteen patients were included. Male to female ratio was 4.3:1. Median age at surgery was 78 months. Eleven patients underwent laparoscopic redo and 5 underwent robotic redo. Median length of follow-up was 49 months. Reasons for redoing were transition zone pull-through, residual aganglionosis, anastomotic retraction or leak, rectal diverticulum, and refractory anastomotic stricture. No major intraoperative complication occurred. No conversion to laparotomy was required. One patient experienced cuff stricture requiring laparoscopic release. Two patients reported bouts of enterocolitis postoperatively. Compared to classic laparotomic redo pull-throughs (49 patients with complete data), overall complications were significantly less frequent, accounting for 1 and 21 events, respectively (6% versus 43%) (P = .0067). Continence after a median of 21 months postoperatively scored excellent to good in 9 out of 12 patients, who were assessed on this regard (75%), without statistically significant differences. Conclusions: MIRPT proved to be effective and safe in HSCR patients complaining postoperative obstructive symptoms. Robotic surgery could play a crucial. Our study confirms that complicated HSCR cases can be safely managed by means of MIS, applying concepts of fast track care to serve the best for our patients.