The versatility of the umbilical incision in the management of Hirschsprung's disease

Background/Purpose: The aim of this report is to describe how the umbilical incision provides a quick and safe alternative to laparoscopy or other abdominal incisions in the management of Hirschsprung's disease (HD). Methods: An analysis of 24 patients with HD, who were treated using an umbilical incision as part of their operative management between 1999 and 2003, was performed. Results: There were 18 boys and 6 girls (mean age at diagnosis: 16.5 +/- 20.9 days). Twenty-one had rectosigmoid HID, and 3 had total colonic HD. Eighteen patients received a 1-stage transanal pull-through with transumbilical colonic biopsies at a mean age of 33.9 +/- 25.3 days, and a mean weight of 3.8 +/- 1.0 kg. Three patients with rectosigmoid disease had more complicated HD: 2 had a colostomy (1 enterocolitis, 1 extensive colonic dilatation), and 1 had an ileostomy (for perforated cecum). All subsequently underwent transanal pull-through. Three patients with total colonic HD had an ileostomy. All stomas were situated at the umbilicus. One of these patients subsequently underwent a Duhamel procedure via the umbilicus; 1 is still waiting; and 1 died of sepsis. Complications in this cohort included a seromuscular tear of the distal sigmoid at the level of the umbilical incision (1), infection at the umbilical incision requiring antibiotics (2), obstruction (1) and death (1 sepsis, 1 from Ondine's curse). The median time to start full feeds was 24 hours. For postoperative analgesia, 13 patients required acetaminophen only, and 9 patients received low-dose morphine. After a mean follow-up of 7.3 +/- 9.7 rnonths, there has been an excellent functional and cosmetic result in the 22 survivors. Conclusions: The umbilical incision has all the benefits of a minimal access approach, but is less expensive and requires no specialized equipment or skill. The umbilical incision is an excellent, safe, and versatile alternative to laparoscopy for the treatment of patients with the full spectrum of HD. (C) 2005 Elsevier Inc. All rights reserved.