Laparoscopic Swenson pull-through: A comparison with the open procedure

doi:10.1016/S0022-3468(96)90107-4

Journal of Pediatric Surgery

Volume 31, Issue 8, August 1996, Pages 1155-1157

https://doi.org/10.1016/S0022-3468(96)90107-4 Get rights and content

Abstract

This study was performed to compare the standard open Swenson pull-through (OSP) with the laparoscopic Swenson pull-through (LSP) for Hirschsprung's disease. The Swenson pull-through was performed on eight patients with a rectosigmoid transition zone, during a 14-month period, using one camera port and three working ports. The results were compared with those of 10 patients with a similar lesion treated by the open procedure during an overlapping 19-month period. One laparoscopic procedure was converted to the open version because of technical difficulties. Both methods had a hand-sewn anastomosis approximately 1 cm above the pectinate line. The preoperative variables of age, weight, incidence of colostomy, and incidence of Down's syndrome were similar for the two groups. The operating time for LSP was similar to that for OSP (4 hours 42 minutes v 4 hours 37 minutes, respectively; P =NS). Postoperatively, the laparoscopic group had a shorter hospital stay (5.25 v 8.8 days; P < .05) and had a shorter period until the start of oral intake (2.75 v 5 days; P < .05). The requirement for narcotic pain medication was similar (12.6 v 12.8 doses; P = NS). Early postoperative complications were more common in the open group (3 wound infections, 1 prolonged ileus, and 1 anastomotic leak). No complications occurred in the laparoscopic group. Late postoperative follow-up was too short to compare functional results. The authors conclude that the Swenson pull-through can be performed safely with the laparoscope, with reduced morbidity.

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Cited by (63)

Laparoscopic-assisted transanal pull-through (LATP) versus complete transanal pull-through (CTP) in the surgical management of Hirschsprung's disease
2016, Journal of Pediatric Surgery
Citation Excerpt :
There was a significant difference in surgery duration between groups, with CTP being completed in less time than LATP (2.6 ± 0.6 h vs. 3.9 ± 1.1 h, p = 0.001). The literature search yielded 423 abstracts, from which 17 articles (12 LATP [12–23], 3 CTP [24–26], and 2 comparative [27,28]) were included (Fig. 1). The main reasons for study exclusion were surgical procedures and outcomes that were not of relevance for this review.
It is unclear whether laparoscopic-assisted transanal pull-through (LATP) or complete transanal pull-through (CTP) is superior for the surgical management of Hirschsprung's disease. We compared outcomes between approaches.
We retrospectively reviewed patients with Hirschsprung's disease who underwent LATP or CTP at our centre between 1995 and 2014. Patients were matched based on age, birth weight, and level of aganglionosis. A systematic literature review and meta-analysis were also performed.
From our data, LATP (n = 24) took significantly longer than CTP (n = 12; 3.9 ± 1.1 vs. 2.6 ± 0.6 h, p = 0.001). There was no difference in length of stay or incidence of postoperative complications. A literature search identified 17 published studies, of which 2 were comparative. Our pooled analysis of comparative studies including our results showed that operative time was significantly longer for the LATP group (OR 1.59, 95% CI 1.21–1.96, p < 0.001). There was no significant difference in major complications (OR 1.75, 95% CI 0.76–4.04, p = 0.19) or length of stay (OR 0.33, 95% CI − 0.41 to 1.08, p = 0.38).
Clinical outcomes are comparable between LATP and CTP. CTP offers shorter operative time without the need for laparoscopic instruments.
Epidemiology of adhesions in infants and children following open surgery
2014, Seminars in Pediatric Surgery
Citation Excerpt :
The incidence in older children was comparable with the adult literature. The aggregate mean incidence of ASBO following major trans-abdominal surgery in infants and older children from 16 papers is demonstrated in Table 2.12,18–31 The total number of patients in these 16 papers amounted to 4328.
Adhesions following intra-abdominal surgery are a major cause of small bowel obstruction. The nature of surgical interventions in children (especially neonates) increases the risk of adhesion-related complications. Following laparotomy in neonates, the collective literature reveals an aggregate mean incidence of adhesive small bowel obstruction (ASBO) of 6.2%; malrotation, 14.2%; gastroschisis, 12.6%; necrotising enterocolitis, 10.4%; exomphalos, 8.6%; Hirschsprung׳s disease, 8.1%; congenital diaphragmatic hernia, 6.3% and intestinal atresia, 5.7%. In children beyond the neonatal period, the aggregate mean incidence was 4.7%; colorectal surgery, 14%; open fundoplication, 8.2%; small bowel surgery, 5.7%; cancer surgery, 5.5%; choledochal cyst, 3.1%; appendicectomy, 1.4% and pyloromyotomy, 0.1%.
Transanal endorectal pull-through for classic segment Hirschsprung's disease: With or without laparoscopic mobilization of the rectosigmoid?
2013, Journal of Pediatric Surgery
It has been suggested that the outcome of transanal endorectal pull-through for classic Hirschprung's disease can be improved by laparoscopically mobilizing the colon before the pullthrough.
Charts of 43 patients (2005–2009) with proven recto-sigmoid aganglionosis were retrospectively analyzed with respect to postoperative outcomes. Twenty-one had been treated with the transanal endorectal pull through (TERPT) and 22 with the laparoscopically assisted TERPT (LTERPT).
Gender ratio, congenital anomalies, preoperative enterostomy, and follow up did not differ between the groups. More colon was resected in the TERPT group: median 25 cm vs. 15 cm in the L-TERPT group (p < 0.001). The TERPT-procedure took less time: median 153 min. vs. L-TERPT 263 min (p < 0.001). Postoperatively, three patients showed colonic torsions after TERPT (p = 0.07). The long-term clinical outcomes did not differ significantly between both groups. There was a significant association between length of resection and obstructive symptoms (OR = 0.92, p = 0.01).
Postoperative and clinical outcomes are similar using the TERPT or L-TERPT to correct classic segment Hirschsprung's disease. Prevention of colonic torsion should be the prime concern during the TERPT procedure. L-TERPT requires laparoscopic equipment and takes more operation time, whereas TERPT leaves no visible scars. The positive relation between the larger length of resection and obstructive symptoms requires additional research.
Advances in pediatric colorectal surgical techniques
2010, Seminars in Pediatric Surgery
Citation Excerpt :
As a result, many surgeons have developed a laparoscopic approach based on their previously preferred open procedure. In this regard, the considerations for choosing a specific dissection technique (Soave, Swenson, or Duhamel) are no different from when using an open approach.62,63,81,82 The procedure begins by using a 3- or 4-port technique to obtain frozen-section biopsies to confirm the transition zone.
The operative management of pediatric colorectal diseases has improved significantly in recent years through the development of innovative approaches for operative exposure and a better understanding of colorectal anatomy. Advances in transanal and minimal access techniques have formed the cornerstone of this innovation, leading to improved functional outcomes, earlier recovery, and superior cosmetic results for a number of colorectal diseases. In this regard, we have witnessed a significant evolution in the way that many of these conditions are managed, particularly in the areas of anorectal malformations and Hirschsprung disease. Furthermore, a more thorough understanding of the pathophysiology underlying encopresis and true fecal continence has led to novel and less invasive approaches to the operative management of these conditions. The goal of this review is to describe the evolution of operative management pertaining to these diseases, with an emphasis on technical aspects and relevant clinical pitfalls.
Transanal endorectal pull-through for Hirschsprung disease: technique, controversies, pearls, pitfalls, and an organized approach to the management of postoperative obstructive symptoms
2010, Seminars in Pediatric Surgery
The transanal endorectal pull-through emerged in the late 1990s as the most recent step in the evolution of the surgical correction of Hirschsprung disease. This operation provides the advantages of a minimal access approach with shorter hospital stay, shorter time to full feeding, less pain, and improved cosmesis with excellent outcomes. This article will review the technical principles of the transanal endorectal pull-through, and will address ongoing controversies in the application of this technique. We will also discuss an organized approach to the problem of obstructive symptoms that may affect a subgroup of patients after the transanal pull-through.
The preliminary study of modified Swenson procedure in Hirschsprung disease
2009, Journal of Pediatric Surgery
Citation Excerpt :
In the Swenson procedure, dissection of the posterior-lateral wall of the rectum down to the deep pelvic floor also requires meticulous attention, keeping the dissection directly on the rectal wall. Laparoscopic approaches have been reported for the Swenson procedure [4,9] as well as the Duhamel [6] and the Soave [5] procedures, suggesting better visualization of pelvic structures may contribute to a safe and effective operation, in addition to a cosmetic advantage. This study has shown that with laparoscopic guidance, our modified Swenson operation may have the additional safety advantage of reduced blood loss.
We have been using the Swenson procedure for more than 3 decades for Hirschsprung disease (HD). Recently, we modified this procedure, leaving the anterior wall below the peritoneal reflection undissected (mSwen). In 2000, we introduced mSwen with laparoscopic guidance (LapmSwen). We hypothesized that (1) omitting anterior wall dissection would not affect postoperative anorectal function, and (2) reduced dissection with better visualization via laparoscopy would reduce operative risks.
Charts of 89 patients with Hirschsprung disease operated on between 1990 through 2005 were retrospectively reviewed. Comparisons between Swen and mSwen, as well as between mSwen and LapmSwen, were analyzed in terms of operating time, blood loss, and complications.
Mean operating times (minutes) were 312 for Swen, 284 for mSwen (P = .152), and 302 for LapmSwen ( mSwen, P = .218). Mean blood loss (mL) were 64.8 for Swen, 60.3 for mSwen (P = .669), and 8.7 for LapmSwen (as compared to mSwen, P = .001). We noted leakage in 7 Swen, 2 mSwen, and no LapmSwen patients. There were no significant differences between Swen and mSwen, or between mSwen and LapmSwen, in the incidence of enterocolitis, constipation, and soiling.
LapmSwen appeared to be comparable to the standard and modified Swenson procedures in most measures. Operative blood loss may be reduced in the LapmSwen approach.

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: Presented at the 1995 Annual Meeting of the Section on Surgery of the American Academy of Pediatrics, San Francisco, California, October 13–15, 1995.

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Laparoscopic Swenson pull-through: A comparison with the open procedure

Abstract

J Pediatr Surg

J Pediatr Surg