A Clinical Comparative Study Of The Transumbilical Single-port, Conventional Laparoscopic And Laparotomic Pull-through For Hirschsprung's Disease

Purpose: Congenital megacolon (Hirschsprung's disease, HD), also known asaganglionosis, is a common congenital abnormity which is characterized bythe absence of ganglion cells in the myenteric and submucosal plexuses of thedistal intestine. A variety of procedures like Swenson, Duhamel and Soavewere evolved with time. With the development of minimally invasive surgery(MIS), laparoscopic approaches have been described for each operations, withexcellent results reported. Although the simple transanal pull-though operationhas been the major approach of the short-segment and common type HD withconvenient, minimal invasive and esthetical effect, but thelaparoscopic-assisted approaches have more advantages on wider indicationand managing the blood vessels of the mesentery. It can also identify thetransition zone by intraoperative biopsy. In this study, three commonprocedures for HD were retrospectively analyzed to contrast and evaluate thefeasibility and safety of laparoscopic MIS especially the transumbilicalsingle-port laparoscopy with transanal endoreactal pull-though for HD, toexplore the corresponding strategy for perioperative complications andprovide feasible suggestions for avoiding intra-operative accidents, decreasingmorbidity rate, improving the post-operative recovery.Methords: The clinical data of194children underwent surgical treatment ofHD were summarized in our hospital from2003to2011. Of them,142weremales and52females(2.73:1). The mean age was28.4±34.8months with arange from46days to14years. The operative methods included traditionalDuhamel procedure(54), Ikeda(26), laparotomic modified Swenon or Soaveprocedure (30) and Boly procedure (2), simple transanal pull-throughapproach(29), conventional laparoscopic modification of Swenson/Soave procedure(29), single-incision laparoscopic-assisted Duhamel procedure(3)and transumbilical single-port laparoscopic modified Soave procedure(21). Allchildren were diagnosed through classical clinical presentation, barium enemaand24hours barum residual evaluation, anoretcal manometry andintraoperative biopsy. A comparison was done among the laparotomic Swenonor Soave procedure(30), conventional laparoscopic Swenson or Soaveprocedure(29) and transumbilical single-port laparoscopic Soave procedure(21)on the operative time, the transition zone, the perioperative complications,thepostoperative blow resuscitation and the follow-up of stooling patterns andcolonic motility.Results: Of the80children,58were common type HD,22were long-segmentHD. Three operative approaches were finished successfully. There were noconversions or intraoperative complicastions in the laparoscopic groups.There were55boys and25girls. The mean age was25.1±29.0months. Theconstituent ratio of each group was similar in age, gender and lesion. Thediagnosis of76cases (95%) was proved by postoperative pathology. Theaverage time of laparotomic procedure was185.2±55.9min, the estimatedaverage blood loss was77.8±23.7ml, the average resuscitation time of blowwas3.4±1.1days and the postoperative complications included woundinfection(3cases), wound disruption(1cases), enterocolitis(3cases) andobstruction(2caes). The average time of conventional laparoscopic procedurewas166.1±56.6min, the estimated average blood loss was23.2.8±7.9ml, theaverage resuscitation time of blow was1.5±0.7days and the postoperativecomplications included enterocolitis(1cases), incomplete intestinalobstruction (1cases), perforation in terminal ileum(1cases). The average timeof transumbilical single-port laparoscopic procedure was161.0±51.5min, theestimated average blood loss was23.3±8.2ml, the average was1.3±0.5daysand the postoperative complications included partial anastomoticdecoherence(1cases), abdominal residuary infection complicated byenterocolitis (1cases). The conventional laparoscopic group andtransumbilical single-port laparoscopic group versus laparotomic group had the less blood loss (P=0.005), short operative time(P=0.036) and rapidpostoperative blow resuscitation(P=0.001). The conventional laparoscopicgroup and transumbilical single-port laparoscopic group were similar to theoperative time, blood loss and blow resuscitation. Laparotomic operation hadhigh rate of wound infection and morbidity. During a follow-up of3months to10years with62patients, the recovered along with the postoperative time,three groups had similar fecal function in each postoperative period except onecase had long-term soiling in laparotomic group. Postoperatively, the bowelfunction obtained normal continence on the whole after three months. Therewere no mortality rate in this series.Conclusions: HD can primitively be diagnosed by classical clinicalpresentation, barium enema and24hours barum residual evaluation andanoretcal manometry. The intraoperative biopsy can identify the affect blowprecisely. Laparoscopic-assisted operation can reduce postoperativecomplications and postoperative recovery time with minimum invasion.Transumbilical single-port laparoscopic procedure for HD has similaroperative effect and perioperative complications comparing with theconventional laparoscopic procedure. Transumbilical single-port laparoscopicprocedure can further reduce the injuries of the abdominal wall and has bettercosmetic result with invisible scar in umbilicus. Although the surgicaltreatment of HD has been familiar with most of the pediatric surgeons, butthere are still some details must be recognizeed. The operative techniqueperformed should be selected individually according to the surgeon familiarityand expertise for the sake of minimal invasion to cure the disease.Furthermore, the patient's postoperative conditions must be monitoredcarefully in order to find and manage the early complications.