Laparoscopic Duhamel pullthrough procedure for Hirschsprung's disease in childhood

Robotic-assisted Swenson procedure for Hirschsprung's disease with a median age of 35 days: a single-center retrospective study

PURPOSE

The treatment of Hirschsprung's disease (HD) in infants with the robotic-assisted Swenson procedure has been rarely reported. In this investigation, we aimed to explore the safety and the efficacy of robotic-assisted Swenson procedure for the HD in infants.

METHODS

From November 2022 to July 2023, 17 cases of HD were treated with the Da Vinci robotic Xi surgical system using a three-port approach. Preoperative, intraoperative, and postoperative data were collected and compared with 43 cases of HD treated with laparoscopy by the same lead surgeon.

RESULTS

The robotic-assisted surgery (RAS) group included 17 infants, and the laparoscopic surgery (LS) group included 43 infants, with a median surgical age of 35 days for both groups. There were no statistically significant differences between the two groups in terms of surgical age, gender, preoperative weight, preoperative hospital stay, preoperative enema time, and incidence of preoperative enterocolitis. Estimated intraoperative blood loss and transfusion rate in the RAS group were both lower than in the LS group, with statistically significant differences. There were no statistically significant differences in early and midterm postoperative complications (anastomotic leaks, anastomotic strictures, enterocolitis, etc.) between the two groups.

CONCLUSION

This study demonstrates the efficacy and the safety of robotic-assisted Swenson procedure in infants.

Hirschsprung disease

Hirschsprung disease (HSCR) is a rare congenital intestinal disease that occurs in 1 in 5,000 live births. HSCR is characterized by the absence of ganglion cells in the myenteric and submucosal plexuses of the intestine. Most patients present during the neonatal period with the first meconium passage delayed beyond 24 h, abdominal distension and vomiting. Syndromes associated with HSCR include trisomy 21, Mowat-Wilson syndrome, congenital central hypoventilation syndrome, Shah-Waardenburg syndrome and cartilage-hair hypoplasia. Multiple putative genes are involved in familial and isolated HSCR, of which the most common are the RET proto-oncogene and EDNRB. Diagnosis consists of visualization of a transition zone on contrast enema and confirmation via rectal biopsy. HSCR is typically managed by surgical removal of the aganglionic bowel and reconstruction of the intestinal tract by connecting the normally innervated bowel down to the anus while preserving normal sphincter function. Several procedures, namely Swenson, Soave and Duhamel procedures, can be undertaken and may include a laparoscopically assisted approach. Short-term and long-term comorbidities include persistent obstructive symptoms, enterocolitis and soiling. Continued research and innovation to better understand disease mechanisms holds promise for developing novel techniques for diagnosis and therapy, and improving outcomes in patients.

The follow-up of the robotic-assisted Soave procedure for Hirschsprung's disease in children

Robotic surgery offers three-dimensional visualization and precision of movement that could be of great value to gastrointestinal surgeons. There were many previous reports on robotic technology in performing Soave colonic resection and pull-through for Hirschsprung's disease in children. This study described the follow-up of the Robotic-assisted Soave procedure for Hirschsprung's disease in children. Robotic-assisted endorectal pull-through was performed using three robotic arms and an additional 5-mm trocar. The ganglionic and aganglionic segments were initially identified by seromuscular biopsies. The rest of the procedure was carried out according to the Soave procedure. We left a short rectal seromuscular sleeve of 1.5-2 cm above the dentate line. From December 2014 to December 2017, 55 pediatric patients were operated on. Age ranged from 6 months to 10 years old (median = 24.5 months). The aganglionic segment was located in the rectum (n = 38), the sigmoid colon (n = 13), and the left colon (n = 4). The mean total operative time was 93.2 ± 35 min (ranging from 80 to 180 min). Minimal blood was lost during the surgery. During the follow-up period, 41 patients (74.6%) had 1-2 defecations per day, 12 patients (21.8%) had 3-4 defecations per day, and 2 patients (3.6%) had more than 4 defecations per day. Fecal incontinence, enterocolitis, and mild soiling occurred in three (5.4%), four (7.3%), and two pediatric patients, respectively. Robotic-assisted Soave procedure for Hirschsprung's disease in children is a safe and effective technique. However, a skilled robotic surgical team and procedural modifications are needed.

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.

Resuturing Without Enterostomy for the Treatment of Early-Stage Anastomotic Leaks After Laparoscopic Soave Procedure in Hirschsprung's Disease

Background: Anastomotic leak (AL) rates gradually decreased with surgical skills and perioperative management progression, but it is still inevitable. As the traditional management of AL after the pull-through procedure of Hirschsprung's disease (HD), enterostomy could lead to multiple surgeries, repeated hospitalizations, increased costs, and enterostomy-associated complications. This study aimed to explore the safety and feasibility of resuturing without enterostomy treating early AL after the laparoscopic Soave procedure. Methods: From October 2014 to June 2019, 10 patients who had AL after the laparoscopic Soave procedure were included. Six patients underwent simply resuturing with presacral drainage; the reoperation time was 1-5 days after primary surgery. Four patients who had diffused peritonitis or severe inflammations received resuturing with an ileostomy, and the reoperation time was 6-11 days. Results: Common early symptoms of AL included persistent fever, sacrococcygeal pain, and abdominal pain. The median delay to reoperation was 1.0 (0-2.25) day. Five patients had leaks at the 3-6 o'clock position, two had leaks at the 6-9 o'clock, and the other three had leaks at the 6 o'clock. The median postoperative fever durations were similar in patients without or with an ileostomy, and the median length of intensive care unit (ICU) stays, duration of antibiotic use, and postoperative length of stay were significantly longer in patients with ileostomy. The mean follow-up time was 38.5 ± 16.7 months (15-69 m). As of the time of writing, no reoccurrence was identified. Conclusion: For patients without diffuse peritonitis, severe inflammations, early diagnosis and timely resuturing of AL within 5 days after the laparoscopic Soave procedure of HD could be a safe, effective, and pleasing treatment.

Primary laparoscopic endorectal pull-through procedure with or without a postoperative rectal tube for hirschsprung disease: a multicenter perspective study

BACKGROUND

Hirschsprung-associated enterocolitis (HAEC) is a significant complication of HD both in the pre- and postoperative periods. This was a large multicenter series study to determine the effect of preserving a postoperative rectal tube on preventing HAEC after primary laparoscopic endorectal pull-through procedure.

METHODS

Between 2014 and 2017, a total of 383 consecutive patients with rectosigmoid segment HD were randomly divided into group A (n = 190) and group B (n = 193). All of them underwent primary laparoscopic pull-through procedure, with the same postoperative treatment protocols except for group A with a rectal tube after surgery for 5 days, while group B did not have it. The mean time of follow-up was 2.0 ± 0.53 years (0.5-3.6 years). Demographics, operative data, postoperative complications, and clinical outcomes were compared between these two groups.

RESULTS

Outcomes within 1 month after surgery indicated a lower incidence of abdominal distention (4% vs 15.5%, P < 0.05) and postoperative HAEC (1.2% vs 6.8%, P < 0.05) in group A compared to group B. Beyond 1 month after surgery, the overall incidence of HAEC was not significantly different (12% vs 13.1%, P = 0.54). However, further analysis revealed that the patients who suffered HAEC twice or above twice in group A were significantly less than those in group B (3.6% vs 8.3%, p = 0.02). There were no significant differences in the defecation frequency and other complications.

CONCLUSIONS

Primary laparoscopic endorectal pull-through procedure with a postoperative rectal tube can reduce the early-stage postoperative incidence of abdominal distension and HAEC and the risk of HAEC recurrence in the long term, and is beneficial to postoperative management.

LEVEL OF EVIDENCE

Level 2.

Laparoscopic Soave procedure for long-segment Hirschsprung's disease - single-center experience

INTRODUCTION

Hirschsprung's disease (HD) is one of the most common and severe diseases treated in pediatric surgery. Since the introduction of the laparoscopic technique into pediatric surgery, laparoscopic-assisted radical surgery for HD has demonstrated unique advantages. Long-segment and total-colon HD are the best indications for laparoscopic-assisted surgery.

AIM

To summarize clinical experience of the laparoscopic Soave procedure for long-segment HD in a single center.

MATERIAL AND METHODS

The data of children with long-segment HD who underwent the laparoscopic Soave procedure in our department from January 2013 to May 2018 were reviewed. The clinical features, surgical procedures and follow-up results were summarized and analyzed.

RESULTS

Thirty-one children underwent the laparoscopic Soave procedure; none of them were converted to open surgery. The average hospitalization time was 8.7 days after the operation, and no immediate postoperative complications occurred. There was no recurrence of constipation. Six (19.3%) cases were complicated with HD associated enterocolitis in the first 3 months postoperatively; 5 (16.1%) cases had soiling in the first year. There were 0 cases of adhesive bowel obstruction, 0 cases of anastomotic stenosis, and 0 cases of constipation.

CONCLUSIONS

A small volume centre may achieve satisfactory results for long-segment HD. The laparoscopic Soave procedure is a minimally invasive, safe and effective treatment.

Transumbilical enterostomy for Hirschsprung's disease with a two-stage laparoscopy-assisted pull-through procedure

BACKGROUND

A one-stage laparoscopic operation has recently been considered a favorable option for the management of patients with Hirschsprung's disease (HD) due to its superior cosmetic results. One-stage transanal endorectal pull-through for the treatment of rectosigmoid HD has been widely used in newborns without complications. However, enterostomy is required in some HD cases for enterocolitis and dilated colon. Our transumbilical enterostomy (TUE) and two-stage laparoscopy-assisted anorectoplasty were effective and achieved a similar cosmetic effect to one-stage laparoscopy on the abdominal wall in patients with anorectal malformation, but the effect in patients with HD is unclear.

AIM

To evaluate the safety, efficacy and cosmetic results of TUE in two-stage laparoscopy-assisted pull-through for HD.

METHODS

From June 2013 to June 2018, 53 patients (40 boys, 13 girls; mean age at enterostomy: 5.5 ± 2.2 mo) who underwent enterostomy and two-stage laparoscopy-assisted pull-through for HD with stoma closure were reviewed at our institution. Two enterostomy approaches were used: TUE in 24 patients, and conventional abdominal enterostomy (CAE) in 29 patients. Eleven patients with rectosigmoid HD had severe preoperative enterocolitis or a dilated colon. 26 patients had long-segment HD, and 16 patients had total colonic aganglionosis (TCA). The patients with left-sided HD underwent the two-stage laparoscopic Soave procedure, and the patients with right-sided HD and TCA underwent the laparoscopic Duhamel procedure. Demographics, enterostomy operative time, complications and cosmetic results were respectively evaluated.

RESULTS

There were no differences between the groups with respect to gender, age at enterostomy, weight and clinical type (P > 0.05). No conversion to open technique was required. Two patients experienced episodes of stomal mucosal prolapse in the TUE group and 1 patient in the CAE group (8.33% vs 3.45%, P > 0.05). No parastomal hernia was observed in either of the two groups. Wound infection at the stoma was seen in 1 case in the TUE group, and 2 cases in the CAE group (4.17% vs 6.90%, P > 0.05). No obstruction was noted in any of the patients in the TUE group, whereas obstruction was found in 1 patient in the CAE group. Enterocolitis was observed in 3 and 5 patients in the TUE and CAE group, respectively (12.50% vs 17.24%, P > 0.05). There was no significant difference between the TUE group and CAE group in terms of the incidence of soiling and constipation (P > 0.05). The cosmetic result using the scar score in the TUE group was better than that in the CAE group (6.83 ± 0.96 vs 13.32 ± 1.57, P < 0.05).

CONCLUSION

TUE is a safe and feasible method for the treatment of HD, and the staged enterostomy and two-stage laparoscopy-assisted pull-through achieved a similar cosmetic effect to the one-stage laparoscopic procedure.

Laparoscopic-assisted Duhamel procedure with ex-anal rectal transection for total colonic aganglionosis

PURPOSE

Laparoscopic-assisted Duhamel procedure has a larger anastomosis and a reservoir which allows early recovery of defecation frequency, but concerns have been raised regarding the long operative time, high incidence of pouchitis and Hirschsprung associated enterocolitis (HAEC). The purpose of this study was to evaluate the postoperative complications and functional outcomes for patients with TCA undergoing modified laparoscopic-assisted Duhamel procedure (MLDP) with ex-abdominal partial colectomy and ex-anal rectal transection.

METHODS

From 2011 to 2014, 16 patients with TCA who underwent MLDP were reviewed at our institution. Main modified techniques were to mobilize partial bowel through abdominal stoma opening, mobilize remaining colon, and dissect the retro-rectal space using laparoscopy, pull out and transect rectum ex-anally using a linear stapling device for creation of a short rectal pouch of 35~45mm. Seven patients who underwent classical laparoscopic Duhamel procedure (CLDP) with a long rectal pouch of 50-60mm between 2009 and 2011 were used as control group. Data were collected including demographics, laparoscopic technique, operative time, stool frequency, complications and continence outcomes.

RESULTS

The operative time in MLDP group was significantly shorter than control group (3.0h vs. 4.7h, p=0.02). The incidence of postoperative HAEC in MLDP group was lower than control group (12.5% versus 42.9%; p=0.03) within the second postoperative year. Two patients (28.6%) experienced episodes of pouchitis in CLDP group and none was found in MLDP group. There was no significant difference in overall functional outcome between two groups, but the performance of MLDP group was better in terms of diapers required than CLDP group (1.80±0.45 vs. 1.00±0.64; p=0.02). All patients after 4years of age had a normal defecation frequency in both groups.

CONCLUSIONS

MLDP is a safe, simple, and reliable technique for TCA. It has fewer postoperative complications due to the short rectal pouch. However, longer follow-up and a larger sample size are necessary to prove the efficacy in the treatment of TCA.

LEVEL OF EVIDENCE

Level 3.

Difference of efficacy between Laparoscopic Modified Soave operation and Open Radical Resection in the treatment of Hirschsprung's disease

Objective

To analyze and compare the efficacy of laparoscopic modified Soave operation and open radical resection in the treatment of Hirschsprung's disease.

Methods

Two hundred and sixteen children who suffered from Hirschsprung's disease and were admitted into the hospital from June 2015 to December 2016 were selected as research subjects. They were grouped into an observation group in which patients were treated by laparoscopic modified Soave operation and open radical resection and a control group in which patients were treated by open radical resection. The clinical efficacy and complications of the two groups were observed, and the defecation function was also evaluated.

Results

Operation indicators such as the operation time, time to recovery of intestine peristalsis, intraoperative blood loss and pain score of the observation group were superior to those of the control group, and the difference had statistical significance (P<0.05). The mean arterial pressure (MAP) and heart rate (HR) of the observation group were lower than those of the control group at all time points after operation, and the difference suggested statistical significance (P<0.05). The postoperative complications of the observation group were less than those of the control group. The follow-up results demonstrated that the excellent and good rate of Kelly score of the observation group was 81.5%, higher than 61.1% in the control group.

Conclusion

Laparoscopic modified Soave operation has definite efficacy in the treatment of Hirschsprung's disease, and the treatment is featured by high safety and few complications, which is beneficial to the recovery of defecation function; hence laparoscopic modified Soave operation is worth clinical promotion.

Laparoscopic Duhamel Procedure with Ex-Anal Rectal Transection for Right-Sided Hirschsprung's Disease

BACKGROUND

Increased defecation frequency and soiling are common complications of surgery for right-sided Hirschsprung's disease (HD). Though the laparoscopic Duhamel procedure is a favorable option in right-sided HD, the conventional laparoscopic technique is time consuming and has complications that are associated with the reservoir. In this study, we described a modified laparoscopic Duhamel technique with ex-anal rectal transection combined with the Deloyer's procedure for right-sided HD.

MATERIALS AND METHODS

Between March 2010 and January 2015, 18 right-sided HD underwent this modified laparoscopic Duhamel procedure (MLDP). The main modifications were to mobilize the colon and to dissect the retrorectal space under laparoscopy, pull out, and transect ex-anally by using a linear stapling device through a transverse incision on posterior wall of the rectum. Seven age-matched patients who underwent a conventional laparoscopic Duhamel procedure (CLDP) between March 2008 and December 2010 were included as the control group. Demographics, surgical procedures, operative data, postoperative complications, and clinical outcomes were compared between these two groups.

RESULTS

Operative time was significantly shorter in the MLDP group (150 minutes versus 195 minutes; P = .03). There was no significant difference in mean timespan to obtain a normal defecation frequency (3.8 months versus 3.6 months), incidence of soiling (11.1% versus 14.3%; P = .34), and constipation (5.6% versus 14.3%; P = .69). Pouchitis were not found in the MLDP group, whereas 2 patients in the CLDP group (28.6%) presented with pouchitis and intractable diarrhea, requiring spur division. The incidence of postoperative enterocolitis was not significantly different in the two groups (11.1% in MLDP versus 14.3% in CLDP; P = .68). All 22 patients had a normal defecation over 4 years of age.

CONCLUSIONS

Laparoscopic Duhamel with ex-anal rectal transection is a simple, easy-to-learn, and effective procedure for right-sided HD. It has low postoperative pouchitis because of a short pouch.

Comparison of Laparoscopic-Assisted Operations and Laparotomy Operations for the Treatment of Hirschsprung Disease: Evidence From a Meta-Analysis

The purpose of this meta-analysis is to compare the relative merits among laparoscopic-assisted operations and laparotomy operations for patients with Hirschsprung disease. PubMed, Web of Science, and Wanfang databases were searched for the related articles. We analyzed dichotomous variables by estimating odds ratios (ORs) with their 95% confidence intervals (CIs) and continuous variables using the weighted mean difference (WMD) with the 95% CI. The random-effects model (REM) was used to combine the results. The outcome measures included operating time (OT), estimated blood loss (EBL), length of hospital stay (LOHS), mean first bowel movement (MFBM), and number of complications. Sixteen articles were included in the meta-analysis. These studies involved a total of 774 patients, 396 of whom underwent laparoscopic-assisted operations and 378 of whom underwent laparotomy operations. The EBL (WMD = -1.48, 95% CI = -1.82, -1.13), LOHS (WMD = -0.67, 95% CI = -0.86, -0.49), MFBM (WMD = -0.83, 95% CI = -1.05, -0.61), and number of complications (OR = 0.60, 95% CI = 0.40, 0.89) were significantly lower in laparoscopic-assisted operations than in laparotomy operations. The OT (WMD = 0.12, 95% CI = -0.05, 0.28) showed no significant differences between laparoscopic-assisted operations and laparotomy operations. Compared with laparotomy operations, laparoscopic-assisted operations are generally safer and more reliable for patients with Hirschsprung disease.

Laparoscopic Duhamel Procedure for Hirschsprung's Disease: Systematic Review and Meta-analysis

INTRODUCTION

Since its introduction in 1956, the Duhamel procedure has been and remains one of the most widely performed for Hirschsprung's disease (HD). The most significant modification to this procedure has been the incorporation of laparoscopy, while the original principles of the method have been retained. This study compared long-term outcomes for open Duhamel (OD) and laparoscopic Duhamel (LD) procedures for HD, to identify any added advantage of the laparoscopic technique.

MATERIALS AND METHODS

We undertook a systematic review of all studies published over a period of 20 years (1994-2014) that assessed functional outcomes for OD and/or LD procedures. Odds ratios were calculated for dichotomous variables, and mean difference values were calculated for continuous variables.

RESULTS

From 11 articles 456 patients were included (253 OD, 203 LD), with no significant difference in age at surgery and length of follow-up (P > .05). The open group had a significantly greater incidence of soiling/incontinence (11% versus 4%; P = .02) and further surgery (25% versus 14%; P = .005), longer hospital stay (9.79 versus 7.3 days; P < .00001), and time to oral feed (4.05 versus 3.27 days; P < .00001). Operative time was significantly longer in the laparoscopic group (3.83 versus 4.09 hours; P = .004). There was no significant difference in incidence of enterocolitis (15% versus 10%; P = .14) and constipation (23% versus 30%; P = .12).

CONCLUSIONS

Our meta-analysis convincingly demonstrates the superiority of LD over OD pull-through for HD. Prospective, randomized control trials are required to overcome limitations in the current literature.

Factors affected by surgical technique when treating total colonic aganglionosis: laparoscopy-assisted versus open surgery

INTRODUCTION

We compared laparoscopy-assisted Duhamel (Lap-D) with open surgery (Duhamel or Soave = D/S) for treating total colonic aganglionosis (TCA) in children to establish what factors may affect outcome.

METHODS

Fourteen TCA cases treated between 1990 and 2010 were reviewed. Open D/S (O-D/S) through a vertical midline abdominal incision was routine from 1990 to 2005, whereupon Lap-D became routine. Lap-D involves laparoscopic colon resection, ileostomy take-down, and ileum pull-through through an additional Pfannenstiel incision. We compared pre-operative nutrition, operating time, intraoperative blood loss, duration until oral challenge, postoperative analgesic usage, incidence of enterocolitis, early complications that arose within 30 days of surgery, and late complications, and wound cosmesis 1 year postoperatively (Grade-1: unacceptable, Grade-2: passable, Grade-3: excellent).

RESULTS

Six had O-D/S (2D, 4S) and eight had Lap-D. Differences in patient demographics, mean ages/weights at surgery, average length of the aganglionic segment from the terminal ileum, operating time, and time taken for oral challenge were all not significant, full feeding took longer in O-D/S (6.7 vs. 5.9 days). Preoperative central vein intravenous hyperalimentation was required for one case in O-D/S and two cases in Lap-D. These three required hospitalization for at least 30 days postoperatively and parenteral nutrition after discharge. Although there were no intraoperative complications in either group, there was one case of transient ileus in O-D/S that resolved conservatively. Cosmesis was significantly better in Lap-D (O-D/S = 1.2; Lap-D = 2.1; p < 0.05).

CONCLUSIONS

Cosmesis was the only factor that was significantly different between Lap-D and O-D/S; all other factors were similar.

Duhamel pull-through assisted by transrectal port: a hybrid natural orifice transluminal endoscopic surgery approach

One of the latest surgical innovations is natural orifice transluminal endoscopic surgery (NOTES). We hypothesize that the principles of NOTES could be applied to the laparoscopic Duhamel procedure. Between March 2008 and May 2010, 3 children underwent the laparoscopic Duhamel procedure assisted by transrectal NOTES. Three 5-mm transabdominal trocars were combined with a 12-mm transrectal trocar. We were able to safely apply the principles of NOTES, improving the performance of laparoscopic Duhamel pull-through using current instruments and technology. This new approach avoids the need of an extra transabdominal 12-mm trocar for the endoscopic stapler, allows an easier creation of a smaller rectal stump, and offers the possibility of an extra working port. This hybrid concept can be seen as a transition into the emerging field of NOTES in colorectal surgery.

Duhamel pull-through for Hirschsprung disease: a comparison of open and laparoscopic techniques

PURPOSE

Various pull-through techniques, both open and laparoscopic, have been performed for Hirschsprung disease. Our study compares open and laparoscopic Duhamel pull-through.

METHODS

After ethical approval, we reviewed all children (n = 181) with Hirschsprung disease admitted to our institution between 1999 and 2009. We excluded total colonic aganglionosis (n = 14), previous pull-through done elsewhere (n = 33), or follow-up performed abroad (n = 58). Open and laparoscopic pull-through were done in the same period according to surgeon preference. Data were analyzed using χ(2) or Mann-Whitney U test.

RESULTS

Seventy-six children had a Duhamel pull-through for rectosigmoid aganglionosis. Operative time, time to full feeds, and length of hospital stay were similar in each group. OPEN (N = 41): Fifteen children (37%) required 33 further procedures. Fourteen had procedures for persistent constipation, including redo Duhamel (n = 2), stoma formation (n = 2), spur division (n = 2), and dilatation/stretch/Botox/rectal biopsy/manual evacuation (n = 23). Three children had other procedures (adhesiolysis [n = 2] and incisional hernia repair [n = 1]). LAPAROSCOPIC (N = 35): Fourteen children (40%) required 30 further procedures. Eleven had procedures for persistent constipation, including redo Duhamel (n = 1), stoma formation (n = 4), spur division (n = 9), and dilatation/stretch/rectal biopsy (n = 8). Three children had other procedures (adhesiolysis [n = 1] and incisional hernia repair [n = 2]). There were 4 conversions.

CONCLUSION

Open and laparoscopic Duhamel pull-through have similar outcomes. We show that the techniques have comparable operative times and hospital stay.

Advances in pediatric colorectal surgical techniques

The operative management of pediatric colorectal diseases has improved significantly in recent years through the development of innovative approaches for operative exposure and a better understanding of colorectal anatomy. Advances in transanal and minimal access techniques have formed the cornerstone of this innovation, leading to improved functional outcomes, earlier recovery, and superior cosmetic results for a number of colorectal diseases. In this regard, we have witnessed a significant evolution in the way that many of these conditions are managed, particularly in the areas of anorectal malformations and Hirschsprung disease. Furthermore, a more thorough understanding of the pathophysiology underlying encopresis and true fecal continence has led to novel and less invasive approaches to the operative management of these conditions. The goal of this review is to describe the evolution of operative management pertaining to these diseases, with an emphasis on technical aspects and relevant clinical pitfalls.

Early and late outcomes of primary laparoscopic endorectal colon pull-through leaving a short rectal seromuscular sleeve for Hirschsprung disease

AIM

To report early and late outcomes of laparoscopic colon pull-through leaving a short rectal sleeve for Hirschsprung disease.

METHODS

Laparoscopic endorectal colon pull-through was performed using 4 ports. The ganglionic and aganglionic segments were initially identified by seromuscular biopsies obtained laparoscopically. The rest of the procedure was carried out according to Georgeson's technique. However, we left a short rectal seromuscular sleeve of 1.5 to 2 cm above the dentate line.

RESULTS

From January 2001 to December 2007, 200 patients were operated upon by the same surgeon. Ages ranged from 14 days to 36 months old. The aganglionic segment was located in the rectum in 112 patients, in the sigmoid colon in 80 children, and in the left colon in 8 patients. The median operating time was 152 minutes. There were no perioperative deaths. Conversion to open surgery was required in four patients. There was minimal blood loss during the surgery. Oral intakes of clear fluid were started 12 hours after surgery and advanced to formula on the second day. In 1 patient, a small intestinal perforation occurred 3 days after surgery, requiring a diverting ileostomy. The mean hospital stay was 6.6 days (range, 4-12 days). Follow-up ranging from 5 to 85 months was obtained in 157 patients; 124 patients (79%) had 1 to 4 defecations a day, 17 (11%) had 5 to 6, and 8 had more than 6. Fecal incontinence occurred in 3 patients (2.0%), constipation in 5 patients (3.0%), and enterocolitis in 15 patients (9.5%). Anastomotic fistula occurred in 2 patients.

CONCLUSION

Laparoscopic endorectal pull-through leaving a short rectal seromuscular sleeve is a safe and effective procedure for Hirschsprung disease.

Recent advances and controversies in pediatric laparoscopic surgery

Children represent a unique group of patients who are likely to greatly benefit from minimally invasive surgery (MIS). The promise of less postoperative pain, smaller scars, shorter hospital stays, and a faster return to school continues to drive growth in this area. The development of pediatric-specific techniques and documentation of improved outcomes form a critical gateway to widespread application of pediatric MIS. A brief perspective on current approaches to MIS for pediatric congenital and acquired disease is provided in this report. Technical departures from standardized adult MIS and the rationale for their modification are highlighted.

Total colonic aganglionosis with or without small bowel involvement: a 30-year retrospective nationwide survey in Japan

PURPOSE

We conducted a nationwide survey in Japan, to identify recent trends in the diagnosis and treatment of patients who had total colonic aganglionosis with or without small bowel involvement (TCSA). These data were compared with 2 similar studies conducted within the last 30 years.

METHODS

Patient data were collected in 3 phases; phase I included 135 patients between 1978 and 1982; phase II, 107 patients between 1988 and 1992; and phase III, 101 patients between 1998 and 2002.

RESULTS

The incidence of TCSA was 1:59,059, 1:58,084, and 1:58,375, and the male-female ratios were 1.5:1, 1.5:1, and 2.2:1 in each phase, respectively. Patients with associated anomalies increased from 15.2% (phase I) to 22.8% (phase III). The incidence of preoperative enterocolitis decreased over time. For treatment, Duhamel's procedure and ascending colon patch methods have increased over time, whereas Martin's procedure has decreased. The mortality rate dropped from 40.9% to 15.8%; however, a high mortality rate persists in those cases with small bowel involvement (35.5%).

CONCLUSIONS

A marked decrease in the overall mortality rate was observed during the study period. However, further efforts are still required especially in cases involving aganglionosis extending orally to 75 cm from Treitz's band.

Is high amplitude propagated contraction present after transanal endorectal pull-through for Hirschsprung's disease?

The transanal endorectal pull-through (TAEPT) procedure is now widely performed for Hirschsprung's disease (HD), however, the colorectal function after TAEPT has not yet been adequately assessed. We evaluated the postoperative clinical outcome and colorectal function based on lower colonic manometry after TAEPT. Twenty-one cases of HD underwent TAEPT from 1998 to 2005. We examined the clinical outcome based on the requirement of enemas/suppositories, the number of defecations per day, the severity of perianal erosion, and the incidence of enterocolitis requiring hospital stay. Using a three-channel Dentsleeve catheter and UPS-2020 measuring device, we performed postoperative colonic manometry at three locations: (1) the anal canal, (2) 5 cm proximal to the anal canal, and (3) 10 cm proximal to the anal canal, during defecation, and then we measured the appearance of high-amplitude contraction (HAC) (duration >/=10 s, amplitude >/=100 cmH(2)O). Four of 21 cases were treated with enemas/suppositories no longer than 1 year. The number of defecations decreased gradually from 4 to 5 per day in the early postoperative period, reaching 2 to 3 per day about 1 year postoperatively. Perianal erosion was noted in 3 of 21 cases but it disappeared within three postoperative years. Two cases had enterocolitis. Lower colon manometry was performed in eight cases. Manometry during defecation was successfully monitored in six cases. HAC occurred in five of six cases (83.3%). The clinical outcomes after TAEPT were satisfactory in almost all cases. These good outcomes were possibly due to the occurrence of HAC during defecation, though HAC did not fill the definition of high amplitude propagated contractions (HAPCs). The occurrence of HAC after TAEPT might be caused by keeping any damage to the mesenteric ascending cholinergic nerve to a minimum during surgery. Further long-term observations are still required to make an adequate assessment of such cases.

Laparotomic versus laparoscopic Duhamel pull-through for Hirschsprung disease in infants and children

PURPOSE

The aim of this study was to analyze the results from laparotomic and laparoscopic Duhamel pull-through in the treatment of Hirschsprung disease.

MATERIALS AND METHODS

In our department, the Duhamel pull-through technique was adopted in most patients and the laparoscopic technique used since 1999 follows the original Duhamel procedure. Patients were identified retrospectively and followed up in our outpatient clinic. Preoperative, operative, and postoperative data were collected and analyzed.

RESULTS

Between January 1992 and March 1999, 21 children with Hirschsprung disease underwent primary surgical correction using the classic open Duhamel pull-through. The mean age at operation was 14 months, the median operating time was 297 minutes, and the average postoperative stay was 10 days. From April 1999 to December 2003, 22 children underwent laparoscopic Duhamel pull-through. The mean age at operation was 14.6 months, the mean operative time was 253 minutes, and the mean postoperative stay was 6.8 days. The rates of early (4.7% vs. 4.7%) and late (19% vs. 23.8%) complications were similar in the two groups, but in the laparoscopic group the mean operative time and postoperative hospital stay were lower.

CONCLUSION

With these encouraging results, laparoscopic Duhamel pull-through has become our procedure of choice in the surgical management of Hirschsprung's disease.

Duhamel procedure: a comparative retrospective study between an open and a laparoscopic technique

Background

Few studies are available comparing open with laparoscopic treatment of Hirschsprung’s disease. This study compares a laparoscopic series of 30 patients with a historical open series of 25 patients.

Methods

The charts of all patients having had a Duhamel procedure in the period from June 1987 through July 2003 were retrospectively reviewed. Open procedures were performed until March 1994. Patients with extended aganglionosis, pre-Duhamel ostomy, or syndrome were excluded from the study. End points were intraoperative complications, postoperative complications, time to first feeding, hospital stay, and outcome at follow-up such as stenosis, enterocolitis, constipation, fecal incontinence, and enuresis.

Results

Twenty-five patients had an open Duhamel (OD) and 30 had a laparoscopic one (LD). There were no differences in patient characteristics and there were no intraoperative complications in either group. Time to first oral feeds was significantly longer in the OD group as was the duration of hospital stay. No significant differences at follow-up were observed but there was a tendency for a higher enterocolitis rate in the LD group. In contrast, the adhesive obstruction and enuresis rates were higher in the OD group. Cosmetic results were superior in the LD group.

Conclusions

Except for a significantly shorter hospital stay and shorter time to first oral feeds in favor of LD, no significant differences could be observed. The cosmetic result was not an end point but there was no doubt that it was better in the LD group. Although not statistically significant different, there were no adhesive bowel obstructions in the LD group compared with 3 of 25 in the OD group. Fecal incontinence was not encountered in either group.

Primary Laparoscopic Endorectal Colon Pull-through for Hirschsprung's Disease: Early Results of 61 Cases

OBJECTIVE

To report early results after a one-stage laparoscopic endorectal colon pull-through for Hirschsprung's disease (HD).

METHODS

Between January 2002 and June 2004, 61 patients underwent primary laparoscopic-assisted endorectal colon pull-through procedure for HD. Ages ranged from 21 days to 36 months. The ganglionic and aganglionic segments were initially identified by seromuscular biopsies obtained laparoscopically. The rest of the procedure was performed according to Georgeson's technique. We left a short rectal seromuscular sleeve 2 cm from the dentate line.

RESULTS

The aganglionic segment was located in the rectum in 33 patients, in the sigmoid colon in 27 patients and in the left colon in one patient. The median operating time was 140 minutes. There were no operative complications or deaths. No conversion was required. There was minimal blood loss during surgery. Clear fluids were given 12 hours after surgery and milk was given on the 2nd day. In one patient, small intestinal perforation occurred 3 days after surgery and required ileostomy. The median hospital stay was 6 days, excluding one patient with intestinal perforation. Spontaneous defaecation occurred in all patients before discharge.

CONCLUSION

One-stage laparoscopic-assisted colon pull-through is a safe and effective procedure for HD.

Laparoscopic-Assisted Transanal Endorectal Coloanal Anastomosis for Hirschsprung's Disease

BACKGROUND

There has been a recent trend in the use of laparoscopic-assisted one-stage pull-through in the management of Hirschsprung's disease (HD). We describe our initial experience using laparoscopy with a transanal coloanal anastomosis as described by Rintala and Lindhal for HD.

METHODS

Six children with biopsy-confirmed HD underwent laparoscopic-assisted pull-through using Rintala's transanal endorectal coloanal anastomosis. The procedure was done through one 5-mm camera port and two 5-mm working ports. The transition zone was identified by seromuscular biopsies obtained laparoscopically. The sigmoid colon and proximal rectum were mobilized laparoscopically. A transanal endorectal mucosal dissection and a coloanal anastomosis were done, using an absorbable monofilament 5/0 polyglyconate suture.

RESULTS

Six children aged 4 weeks to 36 months underwent this procedure laparoscopically. Two cases had to be converted to an open procedure as a result of dense pelvic adhesions. The entire mobilization of the bowel as well as biopsy confirmation of the transition zone was done laparoscopically in all 6 cases. The median operative time was 135 minutes (range, 120-240 minutes). All 6 children tolerated full enteral feeds after 48 hours and the median hospital stay was 7 days (range, 6-10 days). There were no early postoperative complications. Two cases developed mild enterocolitis that resolved with conservative management. The overall functional outcome was good in all cases with no soiling, stool incontinence, or constipation at a median follow-up period of 12 months (range, 4-27 months).

CONCLUSION

Laparoscopic-assisted pull-through, apart from being cosmetically superior, permits obtaining biopsies as well as an adequate mobilization of the bowel. The transanal endorectal coloanal anastomosis technique is simple and easy to perform, with a minimal dissection which causes less damage to the internal sphincter and pelvic nerves.

Long-term results of treatment of Hirschsprung's disease

Many children with Hirschsprung's disease (HD) have a good outcome following surgical treatment, but long-term follow-up studies have identified a number of concerns. Analysis of long-term function in children after surgical management is difficult. The most commonly encountered problems include constipation, incontinence, enterocolitis and the overall impact of the disease on lifestyle (quality of life). Other complications are less frequent. Each of these problems will be discussed.

Staged laparoscopic-assisted pull-through for Hirschsprung's disease

The authors report 3 cases of Hirschsprung's disease that were treated by laparoscopic-assisted transanal pull-through after a colostomy already had been performed. Two of these patients presented with severe enterocolitis, and a primary laparoscopic-assisted single-stage transanal pull through was not feasible. The third patient had a colostomy performed and was referred to us for a definitive procedure. Many centers over the world now perform laparoscopic-assisted single-stage pull-through as a primary modality of management for Hirschsprung's disease. But for a country like India, where patients with Hirschsprung's disease present or are referred late and frequently with enterocolitis, performing a primary procedure is not possible in all cases. However, this has been used as the definitive procedure after performing a diverting colostomy and histopathologic determination of the length of the aganglionic bowel. The procedure gives excellent results and permits early postoperative feeding, early hospital discharge, and good cosmetic results.

Laparoscopic Swenson procedure--an optimal approach for both primary and secondary pull-through for Hirschsprung's disease

BACKGROUND/PURPOSE

Several pull-through procedures are available for the surgical management of Hirschsprung's disease (HD) in children. The authors have adopted a laparoscopic approach since 1995, including laparoscopic Swenson procedure (LSw), both for one-stage primary and 2-stage secondary procedures. The aim of this study was to examine the role of LSw in children with HD in both primary and secondary procedures.

METHODS

From January 1995 to December 2001, 42 children with biopsy-proven HD underwent laparoscopic pull-through procedure for HD. This group included 29 children who underwent LSw, a detailed analysis of which forms the basis of this report.

RESULTS

Sixteen children underwent a single-stage neonatal LSw; the median weight of this group at the time of surgery was 3.2 kg and the median age was 5 days. Secondary LSw was performed in the remaining 13 children, which included 3 children with total colonic HD who underwent laparoscopic total colectomy and LSw. The median operating time was 105 minutes (range, 66 to 175 minutes). The median time to commence full diet was 48 hours (range, 24 to 86 hours), and median time to return to normal play and activity was 72 hours (range, 48 hours to 5 days). There was no difference in operating time between primary and secondary pull-through procedures. There were no intraoperative complications, and no patient required open conversion. Postoperative ileus was noted in 3 children and enterocolitis in 2. The median hospital stay was 4 days (range, 2 to 6 days). Follow-up was between 6 months to 7 years with a median follow-up of 2.2 years. At follow-up, 2 children required laparoscopic antegrade continence enema procedure. A satisfactory continence was noted in 15 of the 19 children who were older than 3 years at the time of last follow-up.

CONCLUSIONS

LSw seems to be a suitable procedure for laparoscopic management of HD in children. LSw is safe and effective, both for primary and secondary type of pull-through procedures, with good short-term results.

Further evidence on totally transanal one-stage pull-through procedure for Hirschsprung's disease

BACKGROUND/PURPOSE

Fifteen consecutive children aged 20 days to 12 years with biopsy-proven Hirschsprung's Disease (HD) underwent a transanal pull-through procedure over a 17-month period. These patients have been divided into 2 groups. The first was a series of 9 patients, which helped us gain familiarity and confidence with technical and postoperative gestational problems, and the second series was of 6 patients, which fully corroborates and adds further evidence on the minimally invasive nature of the technique. Mucosectomy of aganglionic bowel, access to the peritoneal cavity, division of rectosigmoid mesenteric vessels, pull-through of normoganglionic colon, colectomy, and coloanal anastomosis all were performed transanally. Patients underwent a program of progressive anal dilatations and were assessed for postoperative clinical course, continence, constipation, diarrhea, postoperative enterocolitis, perianal excoriations, and anal stricture.

RESULTS

Mucosectomy was done under direct vision. Operating time ranged from 150 to 350 minutes. The average length of bowel resected was 13.5 cm with a range of 8 cm to 25 cm. There were neither intraoperative nor significant postoperative complications. All but 2 patients accepted full oral feedings on postoperative day 2. Mean hospital stay in the first series of 9 patients was 7 days, range, 5 to 12 days; that of the second series of 6 patients was 5 days, range, 4 to 8 days. All children currently experience 1 to 6 bowel movements per day at a follow-up period of 1 to 17 months.

CONCLUSIONS

A one-stage pull-through procedure for HD can be performed successfully with a completely transanal approach. This technique is associated with excellent early clinical results. Many more cases and a longer follow-up period will be required to compare long-term results with other one-stage procedures for definitive treatment of HD.

Transanal endorectal pull-through for Hirschsprung's disease: experience with 68 patients

BACKGROUND/PURPOSE

The aim of this study was to evaluate the indications, results, and complications of transanal endorectal pull-through (TEPT) in the management of recto-sigmoid Hirschsprung's disease (HD).

METHODS

Between November 1998 and March 2002, 68 TEPT procedures were performed in infants and children. The patients' ages ranged from 6 days to 13 years. The primary diagnosis in all 68 patients was Hirschsprung's disease confined to the recto-sigmoid region. All children had their operations done without construction of preoperative colostomy except for one. Follow-up period ranged from 3 to 39 months (mean, 21 months).

RESULTS

The mean operating time was 90 minutes, and average length of bowel resected was 25 cm. Sixty-two patients had satisfactory results without complications. Blood transfusion was needed in only 11 patients. Recovery was very fast, and patients often were hungry within 24 hours. Feeding was resumed within 48 hours. One patient required laparotomy during the procedure owing to injury to the urethra. Two patients required colostomy 3 and 5 days after surgery respectively, because of delayed leakage. Three patients suffered from attacks of enterocolitis 6 to 9 months postoperatively. There was increased frequency of defecation (5 to 15 times daily) for 4 to 6 weeks after surgery in all the patients. There was no constipation, no incontinence, no cuff abscess, and no mortality in any of the patients. Average frequency of defecation was 1 to 3 times daily after 3 months. The cost of the TEPT technique was almost half that of the open surgery.

CONCLUSIONS

TEPT takes less time, has less bleeding, shorter hospital stay, less morbidity, and earlier recovery than similar open pull-through procedures. The hazards and morbidities associated with laparotomy and colostomy may be avoided with a one-stage technique in Hirschsprung's disease confined to the recto-sigmoid region. Careful long-term follow-up is required to assess continence and sexual function.

Primary pull-through for Hirschsprung’s disease

The first report of a successful primary pull-through for Hirschsprung's disease using the endorectal pull-through (ERPT) was by So et al. (J. Pediatr. Surg. 15 (1980) 470; J. Pediatr. Surg. 33 (1998) 673). Subsequently, because of the simplified nature of this approach and the potential for cost savings, several groups have reported excellent results with this procedure. In addition to the ERPT, both the Duhamel and Swenson procedures have been performed in a one-stage fashion. More recently, primary laparoscopic approaches for each of these techniques have been utilized. The purpose of this review is to discuss the technique of primary pull-through, the peri-operative management and a summary of clinical results.

Laparoscopic-assisted pull-through for Hirschsprung's disease

There appears to be a trend in the management of Hirschsprung's disease toward a one-stage surgical correction in the newborn period. After the development of the one-stage laparoscopic-assisted endorectal pull-through in 1995, the minimally invasive approaches have come to dominate the surgical management of this disease. The laparoscopic-assisted pull-through is ideally suited for those patients with aganglionosis confined to the rectum, sigmoid, or proximal left colon. At the time of the operation, a laparoscopic biopsy is recommended to identify, with certainty, the site of the transition zone before performing the colonic mobilization. Advantages of this approach include reduced discomfort, the early initiation of defecation through a normally positioned ganglionic colon and rectum, and reduced postoperative hospitalization.

[Minimally invasive surgery in the treatment of Hirschsprung disease]

STUDY AIM

The treatment of Hirschsprung's disease was improved by the laparoscopic approach. The study aim was to report the results of a short series.

PATIENTS AND METHOD

From December 1996 to January 2000, 13 children (7 boys and 6 girls) were operated for a Hirschsprung's disease with a laparoscopic approach. The mean age at the time of surgery was 6 months. A colostomy had been performed previously in 10 of them. The colostomy was closed and the colorectal anastomosis was performed with Duhamel's technique in 10 and Swenson's in 3. Location of aganglionnic bowel was rectum and sigmoid colon (n = 9) rectum (n = 2) left colon (n = 1), left colon and right transverse colon (n = 1).

RESULTS

The mean duration of the procedure was 160 minutes. One conversion to laparotomy was necessary. One postoperative leak required a temporary colostomy. One intestinal occlusion due to an incarceration of an intestinal loop behind the pulled through colon, required a reoperation. The mean 26 month-follow-up was too short to draw conclusions about functional results.

CONCLUSION

Laparoscopic approach was an important progress in the treatment of the Hirschsprung's disease but, more recently, the transanal approach that we used in the last five patients, seems to be another more important innovation.

Recent advances in the management of Hirschsprung's disease

BACKGROUND

Major advances have occurred in the management of Hirschsprung's disease since Swenson described his definitive operation in 1948. These advances have occurred in the following areas: genetics, neurophysiology, definitive management in the newborn, total colonic aganglionosis (TCA), Hirschsprung's-associated enterocolitis (HAEC), intestinal neuronal dysplasia (IND), and laparoscopic and perineal approaches for definitive pull-through and redo pull-through operations.

METHODS

This paper will focus on the definitive management of the newborn, TCA, and HAEC, areas in which we have had considerable experience at our institution.

RESULTS

We have treated almost 90 newborns with the definitive pull-through with minimum morbidity. We have managed 25 patients with TCA, of whom 5 had total intestinal involvement and died. The remaining 20 have undergone a total colectomy and endorectal pull-through (ERPT), with zero mortality and a very acceptable stooling pattern and continence rate. Our experience with more than 350 patients with Hirschsprung's disease over the past 25 years has demonstrated an incidence of HAEC of between 20% and 30%. During this period, we have performed 19 redo pull-through operations, the majority of which were ERPTs, with results comparable with those seen with a primary pull-through operation.

CONCLUSIONS

The major advances that have occurred in the management of Hirschsprung's disease include the definitive management of the newborn, our understanding of Hirschsprung's-associated enterocolitis and the treatment of this entity, and the recent successful management of the very complex form of this disease, total colonic aganglionosis.

One-stage Soave pull-through for Hirschsprung's disease: a comparison of the transanal and open approaches

PURPOSE

The authors reviewed their experience using the transanal Soave technique, to determine (1) if it offers any advantages over the standard open approach and (2) whether routine laparoscopic visualization is necessary.

METHODS

The case reports of 37 consecutive children less than 3 years old undergoing Soave pull-through were reviewed. Patients were excluded from analysis if they had total colon disease or had a previous colostomy. The patients were divided into 3 groups: open Soave (OS, n = 13), transanal Soave with routine laparoscopic visualization (LVS, n = 9), and transanal Soave with selective laparoscopy or minilaparotomy (TAS, n = 15). Cost was calculated based on hospital stay, operating room time, and use of laparoscopic equipment.

RESULTS

In the TAS group, suspicion of a longer segment led to the selective use of laparoscopy with or without biopsy in 2 children, and the use of a small umbilical incision for mobilization of the splenic flexure in 2. There were no differences among groups with respect to age, weight, gender, transition zone, operating time, blood loss, intraoperative complications, enterocolitis, or stricture or cuff narrowing. Hospital stay was significantly longer in the OS group (median, 7 days; range, 3 to 47) than the LVS (median, 1; range 1 to 6) or TAS (median, 1, range, 1 to 3) groups. Cost (in thousands of dollars) was also higher in the OS group (median, 6.9; range, 3.9-25.7) than the LVS (median, 3.9; range, 3.6 to 6.4) or TAS (median, 3.4; range, 2.2 to 9.4) groups. Repeat surgery was necessary for 4 OS patients: 2 adhesive small bowel obstructions (1 of whom died), 1 twisted pull-through, and 1 recurrent aganglionosis. Three TAS patients required repeat surgery: 1 twisted pull-through, 1 anastomotic leak, and 1 cuff narrowing.

CONCLUSIONS

These data suggest that the transanal pull-through is associated with a significantly shorter hospital stay and lower cost than the open approach, without an increased risk of complications. Because there is no intraabdominal dissection, there probably is a lower incidence of adhesive bowel obstruction. Routine laparoscopic visualization or minilaparotomy is not necessary but should be used in children who are at higher risk for long segment disease.

Analysis of the costs of surgery for Hirschsprung's disease: one-stage laparoscopic pull-through versus two-stage Duhamel procedure

The purpose of this report is to evaluate the cost-effectiveness of a single-stage laparoscopic pull-through for Hirschsprung's disease compared to the traditional two-stage Duhamel procedure. In this series of 33 children, the length of hospitalization (2.5 +/- 3.5 vs 10.6 +/- 3.9, p < 0.01), cost (19,088 +/- 13,075 vs 34,110 +/- 19,443, p < 0.05), and complications were all significantly less with the laparoscopic assisted pull-through compared to the more traditional open approach.

A laparoscopic pull-through operation for Hirschsprung's disease: report of two infant cases

We describe herein a primary laparoscopic pull-through procedure that was successfully employed to treat two infants with Hirschsprung's disease. Mobilization of the rectum and sigmoid colon was performed laparoscopically, and the rectal mucosa was removed via a transanal submucosal resection. After inducing the rectal prolapse intussusceptically, the rectum was circumferentially transected, and the mobilized colon was pulled down through the rectal muscle cuff. Resection of the aganglionic bowel and the coloanal anastomosis, using the Soave-Denda method, was performed outside the anus. Both infants had an uneventful postoperative course with early recovery of bowel movement. Our experience demonstrates that this minimally invasive surgical procedure is feasible for young infants, and we believe that Hirschsprung's disease may be a definite indication for laparoscopic surgery.

Transanal one-stage Soave procedure for infants with Hirschsprung's disease

PURPOSE

Many centers perform a one-stage pull-through procedure for Hirschsprung's disease (HD) diagnosed in infancy. The authors have developed a one-stage pullthrough procedure using a transanal approach that eliminates the need for intraabdominal dissection.

METHODS

Nine children aged 3 weeks to 18 months with biopsy-proven HD underwent a transanal pull-through procedure over a 13-month period. A rectal mucosectomy was performed starting 0.5 cm proximal to the dentate line, and extending proximally to the level of the intraperitoneal rectum. In the first eight children, intraperitoneal position was confirmed with a laparoscope placed through a 3- to 5-mm port in the base of the umbilicus. The muscular sleeve was divided circumferentially to allow full-thickness mobilization of the rectosigmoid junction. Manual transanal traction permitted direct visualization and division of mesenteric vessels with transanal mobilization above the transition zone. Ganglion cells were confirmed by frozen section, and the bowel was transected. The rectal muscular cuff was divided longitudinally, and the anastomosis was completed. The laparoscope confirmed orientation and adequate hemostasis. In a ninth patient, the identical procedure was performed, but with the laparoscope used only for confirmation at the end of the procedure.

RESULTS

Operative time, including frozen sections, averaged 194 minutes (range, 169 to 250 minutes), and the average length of bowel resected was 12 cm (range, 7.5 to 22 cm). Four of the nine patients were discharged on postoperative day (POD) 1, four on POD 2, and one patient with Down's syndrome was discharged on POD 6. Median follow-up was 6 months (range, 3 to 14 months). One death occurred 2.5 months postoperatively secondary to sudden infant death syndrome. Complications included postoperative apnea spells (n = 1), mild enterocolitis (n = 2), constipation (n = 1), anastomotic stricture(n = 1), and muscularcuff narrowing (n = 1); each responded to nonoperative management. Stool output has ranged from four to eight per day.

CONCLUSION

A one-stage pull-through for HD can be performed successfully using a transanal approach without intraperitoneal dissection. This procedure is associated with excellent clinical results and permits early postoperative feeding, early hospital discharge, and no visible scars.

Extra-anal mucosectomy: laparascopic-assisted endorectal pull-through using a prolapsing technique

BACKGROUND/PURPOSE

The mucosectomy of the aganglionic rectal mucosa has been performed transabdominally in the Soave procedure. Recently, mucosectomy with transanal approach was reported both in the laparoscopic and the open surgical procedure. However, the operative view and working field are restricted because the dissection has to be done in the anal canal. The authors report an innovative approach, an extra-anal mucosectomy, to perform mucosectomy in the Soave procedure for Hirschspung's disease in combination with the laparoscopic-assisted prolapsing technique.

METHODS

Four patients underwent laparoscopic surgery for Hirschsprung's disease with extra-anal mucosectomy between 1995 and 1997. One 10-mm and 5-mm ports were used throughout the operation. The rectum was pulled out through the anal canal to create a rectal prolapse and was divided outside the anal canal. The mucosectomy was performed in the everted rectal mucosa outside the anal canal to the level of dentate line. The colon was sutured to the anal mucosa 2 mm above the dentate line. Mean operative time was 3 hours.

RESULTS

The present technique made the whole mucosectomy possible under direct observation.

CONCLUSION

The extra-anal mucosectomy in conjunction with a laparoscopic-assisted prolapsing technique seems to be a safe and reliable modality in the surgical treatment of Hirschsprung's disease.