A Modified Soave Procedure through a Posterior Sagittal Approach for Hirschsprung’s Disease

 Nguyen Thanh Liem, Bui Duc Hau, Hoang Boi Son

National Hospital of Pediatrics, Vietnam

Purpose: To describe the surgical technique and early clinical results of a modified Soave procedure through the posterior sagittal approach (PSAP) for Hirschsprung disease.

Methods: The patient was placed in a prone jack- knife position.The rectum was approached through PSAP keeping the external sphincter intact.The rectum was isolated , then divided approximately 2 cm from the dentate line. The rectum and sigmoid were freed up to the normal segment. The aganglionic segment and ganglion segment was confirmed during the operation by the frozen biopsy.The aganglionic segment and trasitional zone was removed. The rectal mucosectomy started 1cm proximal to the dentate line leaving 1cm of the muscular cuff. Coloanal anastomosis was fashioned 1 cm proximal to the dentate line.

Results: From January 2000 to December 2001,73  patients were operated on by the above technique. The age ranged from 1 month to 36 months.The aganglionic segment was located in the rectum in  46  patients, and in the sigmoid in 27 patients. The average length of bowel resected was  20 cm ( ranged from 10 cm to 35 cm). Combined laparotomy or lapraroscopic surgery was carriet out in 3 patients. There were no operative or postoperative deaths   Anastomotic leakage occurred in  2 patients . Spontanous defecation was achieved in all patients.

Conclusion: PAPS provides an excellent exposure of the operative field compare to the transanal approach , and decrease the major complications seen with the abdominal approach. The modified Soave procedure can easily be performed through PAPS .

Key words: Hirschsprung disease, modified Soave procedure, Posterior sagittal apprroach.

 Corerspondent: Nguyen Thanh Liem

Adress: National Hospital of Pediatrics, 18/879 Lathanh Road, Hanoi, Vietnam

Email: nipliem@hotmail.com

Tl:    84-4-8352615     Fax: 84-4-7 754 448 

Introduction 

A modified technique through the posterior sagittal approach(PAPS) was systematically used for anorectal malformations in our department (1 ). Since January 2000, a modified Soave operation through PAPS was used for Hirschsprung disease. The purpose of this paper was to describe the surgical technique and initial results.

Materials and methods

96 patients with Hirschsprung’s disease were operated upon from January 2000 to July 2002 by the same surgical team. The diagnosis   was confirmed by the intraoperative frozen biopsy.

The operation was perfomed with the patient in a prone jack-knife position.An incision of the cutanous and subcutaneous planes was made from the sacrococcygeal junction to approximately 1 cm from the mucocutanous junction. then extended laterally 1 cm on each side. The incision was continued untill the external sphincter is visible. The coccyx was removed. The dissection on the midline above the external sphincter is continued to the puborectalis. The anococcygeal ligament is divided, then the puborectalis was  pulled down by a retractor to exposure the rectum. The diagnosis was confirmed by a frozen-section biopsy specimen from the distal rectum.A traction suture was placed on the posterior wall of the rectum and then the rectum was gradually mobilized by division of vessels and bands posteriorally and  laterally up to the peritoneal reflection.A small peanut was passed through the space between the rectum and the vagina or the urethra.. The distal rectum was divided 2cm above the dentate line. The proximal rectal stump was closed. The dissection was continued up to the transition zone through to the normal  colon. A second frozen biopsy was taken to confirm the presence of  ganglionic cells..

 Lonestar retractor was placed to exposure the anus then the mucosa of the distal rectum was dettached from the dentate line. The colon was pull through, divided at the ganglionic level, and then the colo-anal anastomosis was fashioned 1 cm above the dentate line.  Excess colon  can be left when the surgeon worried about the security of the anastomosis. All patients in our series were seen in the clinic 3 weeks postoperatively and then at regular 3- 6 months intervals. 

Results 

From January 2000 to December 2001, 96  patients were operate on by this technique, including 84 boys and 12 girls. The age ranged from 1 month to 36 months ( table 1):

 Table 1: Age distribution

The aganglionic segment was located in the rectum in  56  patients, in the sigmoid in 40 patients (table 2)

Table 2: site of aganglionic segment

 .The  length of resected bowel  ranged from 10 cm to 35 cm (table 3):

Table 3: the length of resected bowel

   Combined laparotomy  was carriet out in 2 patients and assisted laparoscopy in one patient. There was no operative and postoperative death.   Anastomotic leakage occurred in  2 patients . Spontanous defecation was achieved in all patients

Discussion

The abdominal approach is the traditional one for Hirschsprung disease(2,3,4).        . However different approach have been used ( 5,6,7,8,9). The PSAP has several  important advantages  compared with the traditional abdominal  approach. The PSAP provides an excellent exposure of the anal canal and rectum. The dissection can be performed more accurate, with less trauma to the adjacent organs due to direct visualization.  The approach allows the surgeon to avoid  complications of the abdominal approach such as herniation, and intestinal obstruction. The patient recovers more quickly with less pain.

     Compared with  Hedlund’s technique, our technique has some differences:

-         The external sphincter complex is completely preserved  which minimizes the risk of fecal incontinence.

-         The anastomosis is fashioned according to a Soave’s modified method, rather than a straight anastomosis. We believe that the anastomosis on the pectinate area with a short muscular sleeve could be safer and has better blood supply by inferior hemorrhoid artery.

   Compared with the transanal approach (8,9), the PSAP provides better visibility, the internal sphincter is less traumatized since the strong retraction of the anus is not applied.

In this study, the PAPS was used successfully  not only for rectal aganglionosis but also for the sigmoid aganglionosis. The combined abdominal approach or laparoscopy were only necessary in three cases.

We have not followed the patients long enough yet short to evaluate a complete function but after the operation all patients had spontaneous defecation .

The results from this study show that the modified Soave operation through PAPS is a good alternative approach in the surgery of HD, and can be used for both the rectal and sigmoid aganlinonois.

References

1. Liem NT, Hau BD.Long-term follow-up results of the treatment of high and intermediate anorectal malformations using a modified technique of posterior sagittal anorectoplasty. Eur J Peditr Surg 2001;11:242-245.

2. Swenson O, Neuhauser EBD, Pickett LK. New concepts of the etiology, diagnosis and treatment of congenital megacolon. Pediatrics 1949;4:201-209.

3. Duhamel B. Une nouvelle operation pour le megacolon congenital. L’abaissement retrorectal et transanal du colon et son application possible au traitement de quelques autres malformation. Presse Med 1956;64:2249-2250

4. Soave F. A new surgical technic for treatment of Hirschsprung disease. Surgery 1964;56:1007-10014.

5. Hedlund H. Posterior sagittal resection for rectal aganglinonosis: preliminary results of a new approach. J Pediatr Surg 1997,32:1717-1720.

6. Posterior sagittal abdominoperineal pull-through : a mew approach to definitive treatment of Hirschsprung disease- initial experience. J Pediatr Surg 1999;34:572-574.

7. Georgeson KE, Cohen RD, Hebra A, et al. Primary laparoscopic-assisted endorectal colon pull-through for Hirschsprung’s disease: a new gold standard. Ann Surg 1999; 229:678-682

8. Shankar KR, Losty PD, Lamont GL,et al. Transanal endorectal coloanal surgery for Hirschsprung’s disease: experience in two centers. J Pediatr Surg 2000;35:1209-1213.

9. De le Torre L, Ortega A. Transanal versus open endorectal pull-through for Hirschsprung’s disease. J Pediatr Surg 2000; 35:1630-1632.

Back