Robotic-assisted proctosigmoidectomy for Hirschsprung's disease: A multicenter prospective study

Abstract

Background: Robotic surgery is a cutting-edge minimally invasive technique that overcomes many shortcomings of laparoscopic techniques, yet few studies have evaluated the use of robotic surgery to treat Hirschsprung's disease (HSCR).

Aim: To analyze the feasibility and medium-term outcomes of robotic-assisted proctosigmoidectomy (RAPS) with sphincter- and nerve-sparing surgery in HSCR patients.

Methods: From July 2015 to January 2022, 156 rectosigmoid HSCR patients were enrolled in this multicenter prospective study. Their sphincters and nerves were spared by dissecting the rectum completely from the pelvic cavity outside the longitudinal muscle of the rectum and then performing transanal Soave pull-through procedures. Surgical outcomes and continence function were analyzed.

Results: No conversions or intraoperative complications occurred. The median age at surgery was 9.50 months, and the length of the removed bowel was 15.50 ± 5.23 cm. The total operation time, console time, and anal traction time were 155.22 ± 16.77, 58.01 ± 7.71, and 45.28 ± 8.15 min. There were 25 complications within 30 d and 48 post-30-d complications. For children aged ≥ 4 years, the bowel function score (BFS) was 17.32 ± 2.63, and 90.91% of patients showed moderate-to-good bowel function. The postoperative fecal continence (POFC) score was 10.95 ± 1.04 at 4 years of age, 11.48 ± 0.72 at 5 years of age, and 11.94 ± 0.81 at 6 years of age, showing a promising annual trend. There were no significant differences in postoperative complications, BFS, and POFC scores related to age at surgery being ≤ 3 mo or > 3 mo.

Conclusion: RAPS is a safe and effective alternative for treating HSCR in children of all ages; it offers the advantage of further minimizing damage to sphincters and perirectal nerves and thus providing better continence function.

Keywords: Continence function; Hirschsprung’s disease; Nerve; Robotic-assisted; Sphincter.

Figure 1

Flowchart of patient selection.

Figure 2

Trocar site in robotic-assisted proctosigmoidectomy. There are three trocar ports, including a straight-cut umbilical trocar and two 8 mm working trocars located 5 cm from the umbilical trocar on either side.

Figure 3

Diagram of pelvic dissection planes and intraoperative images of pelvic dissection. A: Pelvic dissection plane of robotic-assisted proctosigmoidectomy is under the serosa of the rectum or proper rectal fascia extended serous layer below the peritoneal reflection; B: Pelvic dissection under robotic endoscopy; C: Pelvic dissection plane of conventional laparoscopic Soave surgery is performed tightly around the rectal wall; D: Pelvic dissection under laparoscopy.

Figure 4

The pelvic depth in robotic vision before and after pulling the rectum cranially; the depth becomes shallower after pulling. A: Before pulling; B: After pulling.

Figure 5

Comparison of two minimally invasive approaches and dissection length measurement of robotic-assisted proctosigmoidectomy. A: The transanal Soave anastomosis procedure is performed by making a circular incision 0.5-1 cm from the dentate line and dividing the mucosa upward by 0.2-0.4 cm; B: The length of pelvic dissection was 5.5 cm and the length of transanal dissection was 0.3 cm of robotic-assisted proctosigmoidectomy; C: The length of endorectal dissection and transanal dissection in the laparoscopic approach; D: The length of endorectal dissection and transanal dissection in the robotic approach.

Figure 6

Short- to medium-term outcomes of robotic-assisted proctosigmoidectomy. A: Occurrence of normal stool frequency at 1-6 years after surgery; B: Occurrence of enterocolitis at 1-6 years after surgery; C: Annual postoperative fecal continence score analysis among patients aged 4 years or more.