Page 11 - WJOLS - Journal of Laparoscopic Surgery

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endorectal “pull-through” procedure. They found it was and bowel movement started within 24 hours except for
safe and effective when performed in the neonatal period. six patients. The mean time to discharge was 3.7 days.
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Laparoscopy in Hirschsprung’s disease was being They did not find any instances of anastomotic stric-
done from 1992, and it was limited to biopsy, followed ture, postoperative bowel obstruction, wound infection,
by a minilaparotomy and pull-through procedure, as prolonged ileus, pelvic or intra-abdominal abscesses, or
the anesthetic complications were very high. Georgeson wound dehiscence. Ten (12.5%) of the 80 patients were
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et al reported laparoscopy-assisted colon pull-through readmitted to the hospital for complications. Four of
procedure. these 10 patients required postoperative diversion of the
Between November 1993 and September 1994, they did gastrointestinal tract.
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12 primary laparoscopic colon pull-through procedures in Teitelbaum et al published a paper describing a
infants and children. The patients’ ages ranged from 3 days single-stage primary ERPT procedure. Their study
to 6 years. The primary diagnosis in all 12 patients was included 78 infants who underwent a primary ERPT
Hirschsprung disease. All children had their operations procedure. Study duration was from May 1989 to Sep-
without construction of preoperative or postoperative tember 1999.
colostomy. They mobilized sigmoid colon and proximal Mean age at the time of ERPT was 17.8 days of
rectum laparoscopically. A submucosal sleeve was devel- life. They compared primary ERPT with a two-stage
oped transanally to meet the dissection from above. The approach. Their study showed a trend toward a higher
colon was then pulled down in continuity, divided above incidence of enterocolitis in the primary ERPT group
the transition zone, and secured to the anal mucosa 5 to compared with those with a two-stage approach (42.0 vs
10 mm above the pectinate line. Mean postoperative stay 22.0%). Other complications they found were either lower
was 4 days. Laparoscopic visualization provided clear in the primary ERPT group or similar, including rate of
delineation of pelvic structures even in small infants. He soiling and development of a bowel obstruction. Median
concluded that laparoscopic pull-through required no number of stools per day was two at a mean follow-up
more time than similar open procedures, averaging just of 4.1 ± 2.5 years, with 83% having three or fewer stools
over 2 hours, and morbidities associated with colostomy per day. They found that performance of a primary ERPT
formation and closure and the inconvenience of colostomy for Hirschsprung’s disease in the newborn is an excellent
care were avoided with a one-stage technique. Postopera- option. Results were comparable to those of the two-stage
tive sequelae like wound dehiscence and wound infection procedure. They also found a greater incidence of entero-
were avoided due to the laparoscopy. colitis as compared with the two-stage procedure, but the
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Georgeson et al again reported on laparoscopy- multistage pull-through had higher incidence of readmis-
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assisted pull-through for 80 children. The age at surgery sions than an ERPT. They found the ERPT procedure left
ranged from 3 days to 96 months. They discussed no scars and was associated with less postoperative pain
the outcome of primary laparoscopic pull-through in and discomfort, and shortened hospital stay. Short-term
80 patients performed at six pediatric surgery centers function was reported to be very similar to that after
over 5 years. The average length of the surgical procedure open or laparoscopic procedures. They suggested that
was 2.5 hours. Almost all of the patients passed stool one-stage neonatal repair of Hirschsprung’s disease
and flatus within 24 hours of surgery. The average time was associated with less cost and demand of resources
for discharge after surgery was 3.7 days. The transition without jeopardizing functional outcome.
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zone was identified by seromuscular biopsies obtained Westler and Rintala did a study in 40 patients who
laparoscopically. The colon pedicle preserving the mar- had undergone transanal ERPT for Hirschsprung’s
ginal artery was also fashioned endoscopically. The rectal disease between January 2000 and February 2003. Here,
mobilization was performed transanally. They used the they divided patients into three groups: Patients with neo-
endorectal sleeve technique with the anastomosis per- natal primary pull-through (group I, 15 patients), patients
formed transanally 1 cm above the dentate line. operated on beyond the neonatal period (group II,
Sixty-nine (86%) of their 80 patients had a transition 11 patients), and patients with a previous colostomy
zone in the rectum or sigmoid colon. The remaining (group III, 14 patients). All colostomies except one were

11 patients had a transition zone proximal to the sigmoid taken down and pulled through concomitantly with the
colon; one of these patients had total colonic agangliono- transanal procedure.
sis. Seventy (87.5%) of the children were younger than They found no difference in median hospital stay
6 months of age at the time of the pull-through procedure. (group I, 5 days; group II, 4 days; group III, 5 days) and
Operative time averaged 147 minutes. Blood loss was median time to full oral feedings (group I, 4 days; group II,

<10 cc per patient; only one patient had blood transfusion. 2 days; group III, 3 days) between groups. Two patients
They found that there was rapid postoperative recovery (group III) had immediate postoperative prolapse of the
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