Safety and Efficacy of Hook Diathermy in the Dissection of the Mesocolorectum During Laparoscopic-Assisted Pull-Through for Hirschsprung Disease in Low-Resource Settings

Abstract

Background:

Surgical correction is the main line of treatment for the congenital disorder Hirschsprung's disease (HD). Laparoscopic techniques proved their safety and efficacy in previous studies. LigaSure™ is the gold standard for colorectal dissection. However, other sealing methods could be used during the unavailability of LigaSure.

Purpose:

This study aimed to assess the safety profile of the hook diathermy technique compared to LigaSure in colorectal dissection during laparoscopic-assisted pull-through for HD.

Materials and Methods:

This case-control study was held in the pediatric surgery department at Assiut University Hospitals between September 2017 and January 2023. The study included 57 HD patients who were surgically operated on during a laparoscopic-assisted pull-through. They were divided into 2 groups according to the sealing methods: the ligasure group included 25 patients, and the hook diathermy group included 32 patients.

Results:

Both groups had no statistically significant differences regarding age, sex, or weight. The transition zone was present in all patients, and most transition zones were rectosigmoid. No cases reported intraoperative blood transfusion or conversion to an open or transanal approach. Minimum intraoperative blood loss was reported in both groups, with no significant differences. As regards postoperative complications, including bleeding, leakage, perianal excoriation, and enterocolitis, no significant differences between both groups were found.

Conclusion:

The LigaSure and hook diathermy techniques are safe and effective sealing methods for colorectal dissection during laparoscopic-assisted pull-through for HD.

Highlights

Previous studies evaluated the efficacy of the surgical techniques during laparoscopic-assisted pull-through for surgical management of Hirschsprung's disease without referral to the effect of sealing methods.

This is the first study to compare two different sealing methods, which showed promising results toward using any of them.

Introduction

With a frequency of 1 in 5000 live births, Hirschsprung's disease (HD) is a reasonably common congenital illness of the gastrointestinal system that causes intestinal obstruction in children.¹ Most patients with HD are suitable for a definitive primary procedure using either the laparoscopic-assisted pull-through or the primary transanal approach.² The goal of pull-through surgery is to remove a ganglionic segment of the colon, then pull the normal ganglionic segment down to the anus.^3,4

Besides the main instruments required for laparoscopy, additional tools facilitate minimally invasive surgery, including monopolar hook diathermy, endo GIA staplers, a harmonic scalpel, and LigaSure™ vessel sealing devices.⁵ The Reprocessed/Remanufactured LigaSure Sealer/Divider (Medtronic, Minneapolis, MN) is a bipolar electrosurgical instrument intended for use in minimally invasive or open surgical procedures where ligation and division of vessels, tissue bundles, and lymphatics are desired.⁵ A hook diathermy is another technique to dissect capillaries and lymphatics.⁶

Previous studies reported dissection of colorectal folds during laparoscopic-assisted surgical removal of HD using the LigaSure technique.^7,8 However, in low-resource settings and due to the unavailability of LigaSure, replacement of LigaSure with hook diathermy was not assessed before. Thus, the main goal of this study was to compare the LigaSure technique with a hook diathermy technique regarding intraoperative and postoperative events. To the best of our knowledge, this is the first study to compare both dissection techniques in HD patients.

Materials and Methods

This study was conducted at Assiut University Child Hospital. The patients were recruited between September 2017 and January 2023. All patients completed ∼3 months of follow-up.

Inclusion criteria

This includes patients of both sexes and those aged <18 years who were diagnosed with HD and planned for laparoscopic-assisted pull-through using the Soave technique.

Exclusion criteria

Patients or their caregivers who refused to participate in the study were excluded. Also, patients with recurrent disease or who had another pathology were excluded. Other exclusion criteria considered were lost follow-up or noncompliance to scheduled visits postoperatively.

Population

Fifty-seven patients of both sexes and aged <18 years who were diagnosed with HD and managed by laparoscopic-assisted pull-through technique were included in the study and divided into 2 groups according to sealing methods:

LigaSure technique: included 25 patients

Hook diathermy technique: included 32 patients

Study design

This includes a retrospective case–control study.

Sample size

A convenient sample size of 57 patients was selected based on patients' and tools' availability.

Methods

All patient's data sheets were reviewed for age, sex, and body weight. Operative data were recorded, including operative time, intraoperative blood loss amount, need for blood transfusion, presence of transition zone, used procedure (Soave technique), conversion to open or transanal, and intraoperative complications. Any postoperative complication was reported over 3 months of follow-up as bleeding, leakage, perianal excoriations, or enterocolitis.

Surgical technique

The preoperative preparation began 1–2 days before surgery, allowing the child to consume only clear fluids. Routine intestinal preparation was performed (in older children). Colonic irrigations with 10–20 mL/kg body weight of warm saline were administered through a rectal tube passed to a point slightly above the transition zone every 6 hours for the first 2 days, then as often as every 4 hours until the output was clear.

Rectal irrigations, which involve inserting a wide lumen tube into the rectum and repeatedly irrigating it with a modest quantity (10 mL) of saline solution until the output is clear, were used to prepare the colon in newborns and babies. Eight and 4 hours before surgery, oral erythromycin, a local intestinal antiseptic, was administered.

During the general anesthesia induction, a third-generation cephalosporin was administered. Under strictly aseptic circumstances, the patient underwent catheterization. During the laparoscopic portion of the procedure, the patient was positioned supine at the end of the operating table, with the surgeon standing on the right side. To complete the transanal portion of the procedure, the patient was then positioned in the lithotomy position at the end of the operating table with his legs elevated and fixed by a crossbar.

The abdomen was insufflated with CO₂ using an open approach through a 5 mm incision at the umbilicus. Through either the umbilical or epigastric trocar, a 5 mm scope was inserted. Then, a 5 mm port that was somewhat lower in level than the scope port was added at the midclavicular line on the right side of the umbilicus. In the right iliac fossa, the third port was placed next to the second one. A transfixing Silk or Prolene suture was utilized to traction and hang the colon to the abdominal wall when a fourth port was required.

The apparent transition zone in the contrast enema was confirmed on a laparoscopic abdomen examination. After identifying the transition zone, the intestine was elevated, and the rectosigmoid mesocolon was dissected next to the colon's wall using hook diathermy (Standard L hook 8 or 5 mm exposed, Insulated J hook 5 or 3 mm exposed) or LigaSure electrocoagulation (Covidien, Dublin, Ireland) when available. Below the peritoneal reflection, the mesenteric window in the mesocolon was extended distally.

In older children who had a bigger vessel because of hypertrophy of the sigmoid and rectum, the dealing by hook diathermy should be as close as possible to the colonic wall. So, the dissection of the minute vascular branches could occur at the level of the intramural colonic musculature. Also, in this region, it is better to combine hook diathermy with Maryland Dissector. First, the Maryland Dissector was used for the dissection around the small branches of blood vessels and cauterization. Then, the hook diathermy was used for cutting these cauterized vessels by additional cauterizations.

The patient's position was modified to a lithotomy position with a modest pelvic elevation. The Lone Star retractor device or numerous everting silk sutures were used to expose the rectal mucosa to begin the transanal portion. Silk sutures (4/0) with circumferential interruptions were positioned 1–1.5 cm above the dentate line. An oblique circumferential incision of the rectal mucosa was made, 0.5–1 cm above the dentate line, with needle-point monopolar diathermy, and the rectum muscular sheath of the posterior wall was removed to reach the level of the retroperitoneal fold. A circular incision was performed in the rectal muscular sheath to connect with the abdominal cavity.

The proximal colon was resected 5–10 cm above the transition zone, and then full-thickness coloanal anastomosis using absorbable Vicryl 4/0 sutures was done. A rectal tube was inserted to reduce postoperative edema and abdominal distention, especially in neonates. The pneumoperitoneum was established again, and the abdomen was inspected for pedicle twists, internal hernia, or bleeding. The ports were removed after the evacuation of CO₂, and the port sites were closed. The resected spacemen were sent for histopathological examination after marking the proximal and the distal end.

Postoperative follow-up

All patients were followed up for intestinal sound, bleeding, leakage, perineal excoriations, and enterocolitis.

Ethical considerations

Written informed consent was obtained from all participants, and the study was approved by the institutional reviewing board, faculty of Medicine, Assiut University under protocol number (04-2023-300230).

Statistical analysis

All data were tabulated in SPSS sheet version 29. Categorical data were expressed as number and percentage, while continuous data were expressed as mean and standard deviations. The chi-square and Fisher's exact tests were used to compare data of categorical type. Student's t-test was used to compare continuous data. Binary logistic regression was used to assess predictors for postoperative complications using multivariate analysis. A P value <.05 was considered of statistical significance.

Results

This study included 57 patients who were divided into 2 groups according to the method of colorectum dissection; 25 patients were managed by the LigaSure technique, and 32 patients were managed by hook diathermy. The included patients had a mean age of 19.9 ± 4.5 months, and most were males. Neither group had statistically significant differences regarding patients' age, sex distribution, and body weight (Table 1). Rectosigmoid was the transition zone in most patients in both groups, with no statistically significant difference (64% versus 68.8%; P = .71). Both groups had comparable mean operative time (130.8 ± 18.8 minutes versus 140.9 ± 21.5 minutes; P = .07).

Table 1.

Comparison Between Both Groups as Regards Baseline Characteristics, Operative Details, and Intraoperative Complications

	LigaSure™ group (25 patients)	Hook diathermy (32 patients)	P
Age, months
Mean ± SD	20.7 ± 6.9	18.8 ± 5.4	.65
Sex, n (%)			.14
Male	16 (64)	26 (81.2)
Female	9 (36)	6 (18.8)
Weight, kg
Mean ± SD	11.9 ± 4.6	11.5 ± 4.3	.7
Transition zone, n (%)
Rectosigmoid	16 (64)	22 (68.8)	.71
Descending colon	9 (36)	10 (31.2)
Operative time, minutes
Mean ± SD	130.8 ± 18.8	140.9 ± 21.5	.07
Used procedure, n (%)
Soave	25 (100)	32 (100)	.35
Conversion to open, n (%)	0 (0)	0 (0)	.35
Intraoperative complications, n (%)	0 (0)	0 (0)	.35
Intraoperative blood loss, mL, mean ± SD	8.6 ± 4.3	10.1 ± 5	.26

Level of significance <0.05.

SD, standard deviation.

Soave was the procedure used by all patients. No cases were reported to be converted to open surgeries. No cases reported intraoperative complications. The amount of intraoperative blood loss was comparable between both groups (8.6 ± 4.3 mL versus 10.1 ± 5 mL; P = .26) (Table 1). There were no statistically significant differences between both groups regarding postoperative complications (LigaSure versus hook diathermy: 32% versus 37.5%; P = .66). Postoperative bleeding was not reported in any case in both groups.

Postoperative leakage was reported by only 1 patient in the hook diathermy group in the third day postoperatively and was managed conservatively. Perianal excoriation was reported in 17 patients with no statistically significant difference between both groups (LigaSure versus hook diathermy: 7 versus 10; P = .79). One case in each group reported an incidence of enterocolitis, with no statistically significant difference between the 2 groups. Mean hours for regaining digestive function were comparable between both groups, and no significant difference was reported regarding hospital stay duration (Table 2).

Table 2.

Postoperative Course and Complications

	LigaSure group (25 patients)	Hook diathermy (32 patients)	P
Postoperative complications, n (%)	8 (32)	10 (31.2)	.66
Postoperative bleeding, n (%)	0 (0)	0 (0)	.35
Postoperative leakage, n (%)	0 (0)	1 (3.1)	.37
Perianal excoriations, n (%)	7 (28)	10 (31.2)	.79
Enterocolitis, n (%)	1 (4)	1 (3.1)	.86
Recovery of digestive functions, hours, mean ± SD	22.6 ± 5.1	25.2 ± 6.3	.09
Hospital stay, days, mean ± SD	5.7 ± 1.3	5.8 ± 1.4	.87

Level of significance <0.05.

SD, standard deviation.

A prediction model for postoperative complications was done using binary logistic regression, including the technique of colorectum dissection. The reported factors with statistical significance were age (odds ratio [OR]: 0.8) and body weight (OR: 1.8) (P = .041 and 0.027, respectively). Otherwise, all other factors, including the dissection method, did not have statistical significance (Table 3).

Table 3.

Predictors for Incidence of Postoperative Complications

Predictors	B estimate	95% confidence interval		Odds ratio	P
Predictors	B estimate	Lower	Upper	Odds ratio	P
Sex, female–male	0.73292	0.446	9.716	2.08116	.351
Technique of dissection
LigaSure—Hook	−0.11021	0.227	3.531	0.89565	.875
Transition zone: descending colon—rectosigmoid	0.24620	0.274	5.967	1.27916	.754
Age	−0.16012	0.731	0.993	0.85204	.041
Weight	0.63342	1.076	3.297	1.88404	.027
Operative time	−0.00434	0.955	1.038	0.99567	.839

Level of significance < 0.05

Discussion

The LigaSure vessel sealing system is one of the tools recently introduced to minimize the adverse events that occur during laparoscopic or minimally invasive abdominal surgical techniques. LigaSure is used during organ dissection (colorectum). Hook diathermy is another tool used for mesocolon dissection. In low-resource settings, we replaced LigaSure with hook diathermy when performing laparoscopic pull-through surgery for HD.

The mean age of the included patients was 19.9 ± 4.5 months. Almetaher et al. reported that laparoscopic pull-through could be performed for any diseased child within 2 months up to 6 years.⁷ Kumar et al. evaluated the efficacy of the laparoscopic Swenson procedure among 16 HD children with a mean age of 5 days.⁸ Yokota et al. included 27 patients with a mean age of 4 months.⁹ Most of the included patients in both groups were male (64% versus 81.2%), with no statistically significant differences (P = .14). Almetaher et al. and Granström et al. found in their studies a higher male predominance.^7,10

The transition zone was present in the rectosigmoid colon in 64% of patients in the LigaSure group and 68.8% in hook diathermy techniques. The transition zone in the remaining patients was present in the descending colon. The surgeons in poor-resource countries are depending in their surgical intervention on the preoperative contrast study and the visual intraoperative laparoscopic gross pictures. The proximal colon was resected 5–10 cm above the transition zone, which was detected visually. The international guidelines recommend that the colorectal anastomosis be ∼5 cm proximal to the most distal biopsy that exhibits ganglion cells.^11–13

In this study, the mean operative time was comparable in both groups, with no statistically significant difference between the 2 groups (130.8 ± 18.8 minutes versus 140.9 ± 21.5 minutes; P = .07). No cases were required to be converted to open surgery. Intraoperative blood transfusions were not needed for patients in both groups with a comparable amount of intraoperative blood loss (8.6 ± 4.3 versus 10.1 ± 5; P = .26). No statistically significant difference between both groups was reported regarding the intraoperative course, which reflects the safety and feasibility of the hook diathermy technique compared with the LigaSure technique.

Regarding the postoperative course, no cases of postoperative blood loss and 1 case of leakage were reported in a hook group on the third postoperative day and managed conservatively. The conservative management consisted of nothing per mouth, a nasogastric tube, IV fluid, and IV Polymyxin B (100 mg) at a dose of 40,000 units/kg/day, divided into two dosages every 12 hours, and gentamicin (80 mg) at 2.5 mg/kg IM or IV every 8 hours. The median hours to regain peristalsis were comparable between both groups with no statistically significant difference (22.6 ± 5.1 versus 25.2 ± 6.3 hours; P = .09). In this study, both groups were comparable regarding length of hospital stay (5.7 ± 1.3 versus 5.8 ± 1.4; P = .87).

The most typical reported complication was perianal excoriation, with no statistically significant difference between both groups (28% versus 31.2%; P = .8). It was effectively improved by using topical creams containing zinc-based barriers. In concordance with this study, Almetaher et al. reported perianal excoriation as the most typical postoperative complication, and it was observed in 3 of 18 patients.⁷ Deng et al. reported perianal excoriation in 4 of 15 patients after a modified laparoscopic Swenson procedure.¹⁴ Yokota et al. reported perianal excoriation in all patients in the early postoperative period and one during discharge after the modified laparoscopic Swenson procedure.⁹

According to our results, enterocolitis was observed in 1 patient in each group. Likely, Almetaher et al. reported only 1 case of enterocolitis.⁷ Kumar et al. also said that there were 2 cases of enterocolitis among 16 HD patients who underwent pull-through, and these 2 children also had preoperative enterocolitis.⁸ Deng et al. also reported 1 (4.8%) patient in their study.¹⁴ Yokota et al. found a higher percentage of patients complicated by postoperative enterocolitis.⁹

During the study period, no postoperative urological complications were detected. The reason for these zero urological complications is that the hook diathermy was very close to the resected specimen of the colon, away from any important pelvic structures.

Two sealing devices (LigaSure or hook diathermy) were used for the dissection of the mesocolon during the laparoscopic part, according to which patients were divided into 2 groups. There are no significant differences between both techniques regarding intraoperative and postoperative events, confirming the safety of hooking diathermy. Rothenberg and Chang used an ultrasonic scalpel to control the mesocolon in their series.¹⁵ Kumar et al. carefully applied the unipolar diathermy while maintaining a good visualization of the diathermy tip.⁸

Almetaher et al. depended on sealing the mesocolon using monopolar and bipolar diathermy, providing a safe and cheaper colonic dissection.⁷ No studies previously compared LigaSure with the hook diathermy technique in colorectal dissection during pull-through for HD.

Perrin et al. evaluated the efficacy of hook diathermy in the dissection of the mesoappendix in pediatrics, and they concluded that dissection of the mesoappendix using hook diathermy is a safe, quick, and effective method during laparoscopic appendicectomy with low complications and conversion to open rates.¹⁶ Another study confirmed the safety of hook diathermy in laparoscopic cholecystectomy.¹⁷

Conclusion

In conclusion, during the unavailability of the LigaSure sealing method, hook diathermy is considered a safe and effective alternative for colorectal dissection during laparoscopic-assisted pull-through for surgical management of HD with minimal intra- and postoperative complications.

Footnotes

Authors' Contributions

T.S. provided methodology, software, and writing—reviewing and editing. S.M. performed data curation, writing—original draft preparation. A.S. contributed to software and validation.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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