Laparoscopic-assisted transanal endorectal coloanal anastomosis for Hirschsprung's disease

Background: There has been a recent trend in the use of laparoscopic-assisted one-stage pull-through in the management of Hirschsprung's disease (HD). We describe our initial experience using laparoscopy with a transanal coloanal anastomosis as described by Rintala and Lindhal for HD. Methods: Six children with biopsy-confirmed HD underwent laparoscopic-assisted pull-through using Rintala's transanal endorectal coloanal anastomosis. The procedure was done through one 5-mm camera port and two 5-mm working ports. The transition zone was identified by seromuscular biopsies obtained laparoscopically. The sigmoid colon and proximal rectum were mobilized laparoscopically. A transanal endorectal mucosal dissection and a coloanal anastomosis were done, using an absorbable monofilament 510 polyglyconate suture. Results: Six children aged 4 weeks to 36 months underwent this procedure laparoscopically. Two cases had to be converted to an open procedure as a result of dense pelvic adhesions. The entire mobilization of the bowel as well as biopsy confirmation of the transition zone was done laparoscopically in all 6 cases. The median operative time was 135 minutes (range, 120-240 minutes). All 6 children tolerated full enteral feeds after 48 hours and the median hospital stay was 7 days (range, 6-10 days). There were no early postoperative complications. Two cases developed mild enterocolitis that resolved with conservative management. The overall functional outcome was good in all cases with no soiling, stool incontinence, or constipation at a median follow-up period of 12 months (range, 4-27 months). Conclusion: Laparoscopic-assisted pull-through, apart from being cosmetically superior, permits obtaining biopsies as well as an adequate mobilization of the bowel. The transanal endorectal coloanal anastomosis technique is simple and easy to perform, with a minimal dissection which causes less damage to the internal sphincter and pelvic nerves.