Early and Late Outcomes of Primary Laparoscopic Endorectal Colon Pull-Through Leaving a Short Rectal Seromuscular Sleeve for Hirschsprung Disease

Introduction

In 1994, laparoscopic colon pull-through was first introduced for Hirschsprung disease (HD). ¹ Various laparoscopic techniques have been used.^1–3 Among them, the technique described by Georgeson has become the most popular. ³ However, few studies involving a large sample size and with long-term follow-up results have been reported, especially in the newborn. The aim of this study was to report our early and late outcomes of laparoscopic endorectal pull-through leaving a short rectal seromuscular sleeve for HD in the newborn with 47 cases.

Patients and Methods

Forty-seven patients with HD were operated on between January 2003 and August 2009 by the same surgeon. The operation was not indicated for total colonic aganglionosis. Preoperative diagnosis was based on typical clinical manifestations (e.g., constipation, requiring regular enemas) with X-ray finding of narrow distal segment, a transitional zone, and upper proximal dilated segment detected on contrast studies of the rectum and colon. The diagnosis was confirmed by intraoperative frozen biopsy and reconfirmed by postoperative conventional histopathologic study. Preparation of the colon was performed by colonic irrigation with normal saline for 2–3 days. A regimen of metronidazole, third-generation cephalosporin, and aminoglycoside were given during anesthesia induction and continued for 4–5 days.

The abdominal laparoscopy was carried out by using four ports: a 5-mm trocar through the abdominal wall 2 cm above the umbilicus in newborns; a 5-mm trocar in the left iliac fossa; a 5-mm trocar in the right iliac fossa; and a 3-mm trocar above the pubis. CO₂ insufflation was maintained at a pressure of 8 mm Hg. A seromusculature biopsy was taken for frozen section from suspected aganglionic and ganglionic segments. The results were studied by an experienced surgical pathologist. A window on the sigmoid mesentery was created; then, dissection around the rectal wall was performed circumferentially down to the pelvis under the peritoneal reflection approximately 2 cm anteriorly and to the level of the coccyx posteriorly. The sigmoid artery trunk was clipped, then divided. The mesentery was mobilized up to the level of the inferior mesenteric artery. A surgical Lone Star retractor (Lone Star, Stanford, TX) was used to expose the anus for the transanal dissection. A circumferential incision was made in the mucosa at 0.5–1 cm proximal to the dentate line. The submucosal dissection was extended upward approximately 6 cm. The seromuscular layer of the anterior rectal wall was pulled down and divided longitudinally. This layer was then incised circumferentially to free the rectum completely. The seromuscular sleeve was removed, leaving a cuff of 1.5–2 cm in length from the dentate line. Next, the colon was pulled through the anus. The aganglionic and dilated segments were resected. The coloanal anastomosis was fashioned manually 0.5–1 cm above the dentate line. Oral intakes of clear fluids were initiated 12 hours after the operation and advanced to formula on the second day. Anal dilatation was begun at home 15 days after the operation and continued for 1 month in all patients. Follow-up was scheduled for 3 weeks after the date of operation and then at regular 3–6-month intervals.

Results

There were 38 boys and 9 girls, ranging in age from 3 to 30 days. Thirty-one patients had the aganglionic segment located in the rectum (66.0%), 15 in the sigmoid (31.9%), and 1 (2.1%) in the left colon (Table 1). The length of the resected bowel ranged from 10 to 30 cm (Table 2). The operative time ranged from 60 to 210 minutes (mean, 124). There were no intra- nor postoperative deaths. There was minimal blood loss during surgery. Primary coloanal anastomosis was carried out in all patients. Postoperative hospitalization ranged from 4 to 8 days (mean, 5.1). Spontaneous defecation was achieved in all patients before discharge.

Follow-up was obtained in 42 patients (89.4%), with a follow-up ranging from 4 to 72 months (mean, 56.5). All these patients responded well to anal dilatation. Enterocolitis occurred in 1 patient (2.4%). No patient had urinary incontinence. Erectile function, evaluated by the patient's parents, was present in all 34 boys. Overall, 71.4% patients had 1–2 bowel movements per day, and 23.8% patients had 2–3 bowel movements per day. Defecation results are presented in Table 3.

Discussion

The laparoscopic approach has several important advantages over the traditional abdominal approach. It provides clear delineation of pelvic structures and better cosmetic results. Intestinal function is minimally disturbed. Oral feeding can be resumed soon after an operation. Laparoscopy can determine the transition zone histologically and can also avoid twisting, bleeding, and tearing in the mesenteric vessels as experienced with a transanal approach.^4–9

Our results showed that laparoscopic pull-through was associated with a low rate of postoperative complications. Early anastomotic leakage was not encountered in our series. It has been seen in from 5.6 to 11.2% of cases in some series when using open surgery.^6,7 This complication also occurred in 1.5–2.9% of cases when using the transanal approach.^8,9 Primary anastomosis has been performed safely in all patients. However, the colon stump should be left and removed in a second operation if anastomotic security is not ensured. No anastomotic stenosis was seen in our series. This rate compares to what occurred in that reported for open surgery or the transanal approach.^5,6 We had no cases of rectal stenosis requiring daily dilatation. The rate of enterocolitis in our series was 2.4%, compared with 71.4%.

A short cuff could be an important factor in reducing severe rectal stenosis and enterocolitis. In the transanal pull-through, Nasr and Langer also noticed that the incidence of enterocolitis and rectal stenosis requiring daily dilatation decreased in the short-cuff group, in comparison with the long-cuff group. ¹⁰ In the laparoscopic colon pull-through, one can remove not only the aganglionic segment and transitional segment, but also the malfunctioned dilated segment, because the length of colonic mesentery vessels is always sufficient. This may further reduce the rate of postoperative enterocolitis.

Defecation function was satisfactory in long term follow-up. 71.4% of patients had 1 - 2 bowel movements per day. All patients maintained urinary continence. Erectile function was not impaired in male patients reflecting good protection of the pelvic nervous system in our laparoscopic colon pull-through operations. The dissection close to the rectal wall was mandatory to avoid injury to adjacent structures.

Conclusions

In conclusion, primary laparoscopic endorectal colon pull-through leaving a short rectal seromuscular sleeve had satisfactory early and late outcomes.