| Objective:Hirschsprung's disease(HSCR),which occurs in about 1/5000 human live births with an approximately 4/1 male/female ratio,is the second commonly congenital disorder of the digestive system follow the congenital anorectal malformations.It is characterized by the absence of ganglion cells in the enteric nervous system(ENS)of the distal gut.The ENS provides the intrinsic innervation of the bowel and the absence of ganglion cells in the ENS leads to tonically contracted of the distal gut,which causes the clinical present of delayed meconium,intractable abdominal distension,severe constipation and functional obstruction as a result.Since it was first described by Harald Hirschsprung,a Danish pediatrician of Queen Louise Hospital,at the Society of Pediatrics in 1886 in Berlin,it has drawn great attention of scholars both at home and abroad and a list of researches about its etiology and pathogenesis,diagnosis,treatment have published successively.In 1948,Swenson performed the first successful operative procedure for HSCR with the resection of the colon from a point proximal to dilatation area and the narrow distal rectum and performing a coloanal anastomosis(the Swenson procedure).This was a historic landmark event and the complex congenital disorder of the ENS has been treated effectively since then.But some considered this a tedious operation and the results were not quite as good in other people's hands because of all dissection of the pelvis to excise all the aganglionic segment may traumatize the pelvic nervous supplying to the bladder or the genitals.As a result,a number of modified operations based on the Swenson procedure appeared in the following days such as the Duhamel procedure,the Rehbein procedure,the Soave procedure and its modifications to reduce the postoperative complications.As Georgeson first performed a laparoscopically assisted Soave endorectal pull-through procedure to avoid an open laparotomy,the 1990s and the first few years of the 21st century has been the era of continued technical modifications towards minimally invasive surgery from staged procedures to one-stage procedures without colostomy earlier in life.The laparoscopically assisted procedures and the transanal endorectal pull-through procedure minimalized the surgical traumas furtherly and gained wide acceptance by pediatrician all over the word over the past two or three decades.With the development of diagnosis and the improvement of the level of anesthesia,children with HSCR can received a one-stage radical surgery in neonatal period after definite diagnosis.At the same time,Single-incision laparoscopic surgery(SILS)and natural orifice translumenal tendoscopic surgery(NOTES)has gained acceptance as a method to reduce visible abdominal scars.Enterocolitis and colon perforation are the most common causes of significant morbidity and death in HSCR.When a neonate with HSCR has a colon perforation or enterocolitis,initial life-saving colostomy surgery must be performed.The second stage radical operation must contend with abdominal cavity adhesions,and a pull-through laparotomy is commonly performed traditionally.Based on the development of laparoscopically assisted surgery and the thinking that the TriPort can be inserted from the 1.5-2cm isolated colon fistula to perform a single-incision laparoscopic surgery avoiding the incision of abdominal wall else,which can minimalize the surgical traumas and postoperative pain and visible scars,we introduce transanal abdominal wall colostomal SILS and provide a comprehensive and detailed comparison with the open procedure to evaluate the advantages of this minimally invasive laparoscopic surgery.Methods:Collect the HSCR patients with one-stage colostomy surgery due to the colon perforation,severe enterocolitis or other reasons.All the cases must be confirmed by postoperative full-thickness pathological examination with the absence of ganglion cells in the enteric nervous system of the narrow distal gut.On the basis of the variations in the length of aganglionic segment by intraoperative and postoperative pathological examination,we choose the long segment HSCR(L-HSCR)and the common segment HSCR(C-HSCR)as our research objects,excluding the total colonic aganglionosis(TCA).A total number of 37 children diagnosed with HSCR after one-stage colostomy were evaluated in this study from 2008 to 2014.Nineteen patients treated with the Soave pull-through combined with an open approach to isolate the abdominal adhesions and colon from June 2008 to May 2011 were in open group,and 18 patients treated with a trans colostomy single-incision laparoscopic Soave pull-through approach,which the abdominal adhesions and colon were isolated under laparoscopy,from 2011 to 2014 were in laparoscopy group.A retrospective analysises of the age,sex and the variations in the length of aganglionic segment of every patient in both group were made before the second stage radical surgery.The preoperative dates such as serum total protein,serum albumin hemoglobin,blood urea nitrogen(BUN)and the length and weight of the body were measured also before surgery to assess the nutritional status of each group.During surgery,the operation time,blood loss,the length of incision and side-injury frequency were recorded to evaluate the safety and feasibility of the surgery.In the postoperative hospital stay,the detailed dates of the time of postoperative return to feeding,hospitalization days,the short term postoperative defecation frequency and the postoperative complications such as abdominal wound infection,anastomotic leakage,postoperative intestinal obstruction,abdominal infection and postoperative enterocolitis were harvested.Patients after discharge,we made a long-time follow-up through outpatient service to collect the postoperative complications such as recurrence of constipation,intestinal obstruction,retraction,prolapse,diarrhea,diaper rash and anal stenosis.After all the dates were collected,a comprehensive and detailed comparison with the open group and the laparoscopy group to evaluate the advantages of this minimally invasive laparoscopic surgery.Results:All surgery of HSCR patients was successfully completed,and no case of laparoscopy group was converted to open surgery.There was no death case.The average ages of open group and laparoscopy group at first-stage colostomy and second-stage radical surgery were 20.8±5.5 vs.21.9±3.2 days and 5.8±2.15 vs.6.2±2.07 months,respectively.The male/female ratios of open group and laparoscopy group were 14/5 and 13/5,which were consist with the male/female ratio of HSCR.There were 11cases of L-HSCR in each group and the rest cases were C-HSCR,with a transverse colon colostomy and sigmoid colon colostomy at the first-stage surgery respectively.Through 3-6 months of feeding and preoperative preparation,the nutritional status was similar between each group,which decreased the error of comparison.The comparison of operative times between open group and laparoscopy group was 172 ± 17.8 vs.175± 20.7 mins,which was similar between the two groups with no statistically significant.But laparoscopy group had shorter length of incision(2.5±0.5cm vs.6.2±1.3 cm P<0.05),less blood loss(12.5±6.2 ml vs.47.3±7.1 ml,P<0.05),less side-injury(0 vs.2/19,10.5%)during the surgery due to the excellent operative visualization of laparoscopic surgery.There were fewer hospitalization days(6.2±1.5 vs.13.1±1.8,P<0.05)and earlier postoperative feeding(3.1±1.8 vs.8.2±2.1,P<0.05)in laparoscopy group also,because the laparoscopic surgery minimalized the surgical traumas and promoted the postoperative recovery.The postoperative defecation frequency was similar in the two group and the postoperative defecation frequency decreased along with time.Among the postoperative complications,there were no abdominal infection,anastomotic leakage,anal incontinence,prolapse and diarrhea in the two groups;however,the incidence of abdominal wound infections(0 vs.2/19,10.5%),postoperative intestinal obstruction(0 vs.2/19,10.5%),enterocolitis(0 vs.1/19,2.26%),recurrence of constipation(0 vs.1/19,5.26%),retraction(0 vs.1/19,5.26%),diaper rash(1/18 5.56%vs.2/19,10.5%)and anal stenosis(0 vs.2/19,10.5%)were all lower in laparoscopy group than open group.Conclusions:Transcolostomy single-incision laparoscopic technology can be applied to the second-stage radical surgery for the treatment of HSCR after the first-stage colostomy and the transcolostomy single-incision laparoscopic Soave procedures an effective operative procedure with great safety,which minimalizes the surgical traumas by avoiding the further incision of the abdominal wall to gain a smaller visual postoperative scar due to its excellent operative visualization of all the abdominal cavity and pelvic.The transcolostomy single-incision laparoscopic Soave procedure is a minimally invasive laparoscopic surgery with a lower blood loss,lower incidence of side-injury,fewer times of postoperative recovery and postoperative complications,but needs a more excellent operation skills and experiences. |
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