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

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.

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.

Minimally Invasive Surgery for Hirschsprung Disease: Current Practices and Future Directions

Hirschsprung disease (HD) is a congenital disorder characterized by the absence of ganglion cells in the distal colon and rectum, leading to functional obstruction and severe constipation. Over the past decades, the surgical management of HD has significantly evolved, with minimally invasive surgery (MIS) techniques revolutionizing treatment approaches. This review explores recent innovations in MIS for HD, focusing on laparoscopic, transanal endorectal pull-through (TERPT), and robotic-assisted techniques. These approaches offer numerous advantages over traditional open procedures, including reduced surgical trauma, improved cosmesis, faster recovery times, and potentially lower complication rates. Laparoscopic surgery has become widely adopted, providing excellent visualization and precise dissection. TERPT has gained popularity for short-segment disease, offering a completely transanal approach with minimal scarring. Robotic-assisted surgery represents the cutting edge, enhancing surgical precision and dexterity. The review also examines emerging technologies and future directions, such as advanced imaging techniques, artificial intelligence applications, and potential developments in tissue engineering. While MIS techniques have shown promising outcomes, challenges remain in standardizing approaches, addressing long-segment disease, and optimizing long-term functional results. The future of HD surgery lies in personalized approaches that integrate genetic and molecular profiling with advanced surgical technologies. As the field continues to evolve, comprehensive long-term studies and efforts to improve access to specialized care will be crucial to further enhancing outcomes for patients with HD.

Hirschsprung's disease. Management

BACKGROUND

Hirschsprung's disease (HD) is a rare congenital disease that is characterised by the absence of ganglion cells in the myenteric plexus starting in the distal bowel. This results in distal functional obstruction and may lead to complications like enterocolitis. The treatment is surgical and requires the resection of the aganglionic segment, and the pull-through of normal intestine into the anal opening. However, even after successful surgery, patients may continue to have symptoms.

AIM

Discuss current surgical techniques and management strategies for patients with postoperative symptoms after surgical correction of Hirschsprung's disease.

METHODS

A review of the literature was done through PubMed, with a focus on clinical management and approach.

RESULTS

We describe the clinical problems that can occur after surgical correction. These include obstructive symptoms, enterocolitis, or faecal incontinence. A systematic approach for the evaluation of these patients includes the exclusion of anatomic, inflammatory, behavioural or motility related factors. Depending on the severity of the symptoms, the evaluation includes examination under anaesthesia, the performance of contrast studies, endoscopic studies, measurement of anal sphincter function and colonic motility studies. The treatment is focused towards addressing the different pathophysiological mechanisms, and may include medical management, botulinum toxin to the anal sphincter or rarely redo-operation.

CONCLUSIONS

Patients with Hirschsprung's disease need to have surgical correction, and their postoperative long-term management is complex given a variety of associated problems that can occur after surgery. A systematic evaluation is necessary to provide appropriate therapy.

Single-port plus one in pediatric robotic-assisted Lich-Gregoir ureteral reimplantation for vesicoureteral reflux, a comparative analysis with short-term outcomes

OBJECTIVE

To observe the safety and short-term outcomes of a new way of laparoscopic trocar placement in pediatric robotic-assisted Lich-Gregoir ureteral reimplantation for vesicoureteral reflux.

METHODS

The retrospective study included 32 patients under 14 years diagnosed with primary vesicoureteral reflux (VUR). All these patients underwent robotic-assisted Lich-Gregoir ureteral reimplantation in our department from December 2020 to August 2022. These patients were divided into the following groups according to the different ways of trocar placement: 13 patients in group single-port plus one (SR) and 19 patients in group multiple-port (MR). Patients' characteristics as well as their perioperative and follow-up data were collected and evaluated.

RESULTS

There was no significant difference in the data regarding patients' characteristics and preoperative data. These data included the grade of vesicoureteral reflux according to the voiding cystourethrogram (VCUG), and the differential degree of renal function (DRF) at the following time points: preoperative, postoperative, and comparison of preoperative and postoperative. There was no difference between the two groups. During surgery, the time of artificial pneumoperitoneum establishment, ureteral reimplantation time, and total operative time in the SR group were longer than those in the MR group. Yet only the time of artificial pneumoperitoneum establishment shows a statistical difference (P < 0.0001). Also, the peri-operative data, including the volume of blood loss, fasting time, hospitalization, and length of time that a ureteral catheter remained in place, and the number of postoperative complications demonstrate no difference. In addition, the SFU grade and VCUG grade at the following time point also show no difference between the two groups.

CONCLUSION

The study demonstrates that SR in robotic-assisted Lich-Gregoir ureteral reimplantation has reached the same surgical effects as MR. In addition, the single-port plus one trocar placement receives a higher cosmetic satisfaction score from parents and did not increase the surgical time and complexity.

Establishment and implementation of a clinical application and research database for surgical robots in China

Robots are widely used in surgeries worldwide. To improve robotic surgical treatments, we established a database of clinical applications and research on surgical robots. Robotics‐related literature included in the China national knowledge infrastructure (CNKI), Wanfang, Vipshop, Chinese science citation database (CSCD), Web of Science, EMBASE, PubMed, and Cochrane databases up to September 2022 was searched and entered into the database. Information on all patients who had undergone robotic surgery at our hospital since 2016 was also included. Literature and case information was classified and evaluated according to standard guidelines and statements. The Gansu Provincial Hospital was the first to use evidence‐based medical research methods to successfully establish a database of clinical applications and research on surgical robots. This database comprised literature search, upload, quality evaluation, risk of bias assessment, case information entry, and access functions. Based on the database, we conducted related studies in general surgery, gynecology, urology, thoracic surgery, and cardiovascular surgery, and published 16 meta‐analyses and 15 clinical studies. Establishing this database removes language, retrieval, and evaluation barriers in clinicians' use of clinical evidence and lays the foundation for the efficient and accurate use of clinical data for future research. Further, it facilitates evidence‐based evaluation of the effectiveness of robotic therapy, which may guide future medical practice. This typical case of interdisciplinary research aims to build a platform to disseminate knowledge and technology in robotic surgery.

This article is categorized under:

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.

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.