A Provisional Experience with Robot-Assisted Soave Procedure for Older Children with Hirschsprung Disease: Back to the Future?

Abstract

Hirschsprung disease is a congenital disease characterized by intestinal aganglionosis of various extents. Most patients are younger than 1 year of age. Though, a minority of cases can be older or even adult. Older the patient the more difficult and prolonged is the endorectal dissection required for the pull-through procedure. Longer surgery leads to longer anal dilatation and trauma with subsequent higher likelihood of continence impairment. The article aims at describing the first case series of robot-assisted Soave procedure, which was adopted as an alternative minimally invasive approach to older patients with Hirschsprung disease. The technical principles are represented by intraoperative seromuscolar leveling biopsies, intracorporeal endorectal cranial dissection, and endorectal pull-through with colo-anal anastomosis. The authors report three procedures that were carried on without complication with a limited requirement for anal dilatation and trauma, given the reduced need for endorectal caudal dissection. The results demonstrate the feasibility of the proposed approach. The robotic approach should be considered as an alternative minimally invasive approach for older children or adults with Hirschsprung disease.

The follow-up of the robotic-assisted Soave procedure for Hirschsprung’s disease in children

“…To the best of our knowledge, our study is the largest series of robotic-assisted surgery for Hirschsprung's disease in infants. The total operative time was shorter than previous reports, especially in the robotic console component (mean, 93.2 min; range: 80 -180 min; mean console time, 57.7 min) [11,13]. The factor that can explain this difference is that our department has a lot of patients with HD and we are trained and operated to use proficient techniques in open surgery, laparoscopic surgery, so when conducted robot surgery, our operative time was shorter than other authors with the advantages of robot surgery.…”

“…Reduced sphincters stretching and less endorectal dissection are required in robotic surgery compared to conventional laparoscopic surgery. Moreover, easier seromuscular dissection can be performed down to 2–3 cm above the pectinate line in robotic surgery [ 11 , 13 ]. The disadvantages of robotic surgery are well documented.…”

“…Currently, robotic surgery outweighs laparoscopic surgery due to its advantages of superior visualization and dexterity, tremor reduction, as well as a faster learning curve [8][9][10][11][12][13]. In 2011, Hebra et al had the first report of Robotic Swenson pull-through for HD in twelve infants [11].…”

“…In 2011, Hebra et al had the first report of Robotic Swenson pull-through for HD in twelve infants [11]. Rickey et al (2013) reported a robotic-assisted Soave procedure in a young adult [12], and Mattiolo et al (2017) had applied this technique for older children or adults with HD [13].…”

Application and prospects of robotic surgery in children: a scoping review

“…34 In 2017, Mattioli et al reported three cases of robot-assisted Soave procedures for HSCR in children aged 5 years, 16 years and 20 months. 32 According to the postoperative follow-up data of different centers, the clinical results of RAS are satisfactory, with no postoperative incontinence, good defecation function, and a low incidence of postoperative enterocolitis. [32][33][34][35] Prospective studies of small samples found that Soave surgery performed by RAS could be successfully completed without intraoperative complications, and the incidence of postoperative complications was significantly reduced.…”