Since the first description of Harald Hirschsprung in 1889 [1], the choice of rectal dissection technique is controversial, although the three primary options remain full-thickness dissection with end-to-end anastomosis as described by Swenson in 1948 [2], and Duhamel’s retro-rectal anastomosis or Soave’s extra-mucosal dissection which were developed later [3, 4]. During the 1980s, one-stage (primary) procedures were proposed for uncomplicated cases, thereby avoiding the morbidity associated with stoma formation [5]. In 1995, Georgeson et al. [6] described a minimally invasive approach using laparoscopy for colonic biopsies and mobilization followed by transanal endo-rectal dissection of the rectum using submucosal dissection ( Soave technique) and then colo-anal anastomosis. Subsequently, laparoscopic Swenson and Duhamel-type procedures have been described [7, 8]. In 1998, De La Torre et al. reported the first entirely transanal primary endorectal pull-through without laparoscopic assistance. The transanal Swenson-type procedure has been reported but no case-controlled data have been published [9, 10].

Benefits of entirely transanal primary endo-rectal pull-through include utilization of a single incision and the avoidance of abdominal wall scarring, with the potential for better cosmoses and reduced postoperative pain, a shorter operating time and the suitability of this technique for use in resource-poor settings which may lack equipment for laparoscopy [11,12,13]. Potential disadvantages regarding a totally transanal approach include the possible impact of prolonged dilation of the sphincter muscles on fecal continence [14, 15], the risk of colonic torsion, and the inability to confirm the histological transition zone prior to starting mobilization of the colon as many surgeons would change their operative approach when faced with longer segment aganglionosis [16].

Aim of the study

The aim of this study is to compare outcomes for patients with Hirschsprung’s disease undergoing a TERPT procedure with those undergoing a laparoscopically assisted transanal pull-through (LAPT) using Swenson procedure in both groups.

Patients and method

The study included forty patients with HD disease operated on from January 2018 to January 2022. Twenty patients were operated upon using (TERPT) and twenty patients were operated using (LAPT).

Exclusion criteria 1.

Patients with associated co-morbidity

2.

Previous surgery for Hirschsprung’s disease.

3.

Patients with suspected other cause of chronic constipation

4.

Patients presented with enterocolitis or obstruction.

5.

Patients with associated major gastrointestinal anomalies.

Preoperative evaluation

After detailed history and full physical examination, each patient underwent the proper investigations to confirm the diagnosis and assess the fitness for surgery. Consent is taken after discussing with the parents the details of the procedure, expected benefits and possible intra- and postoperative complications. Also, parents were told that the results of this study will be published, and consent for publication is taken. Detailed history was taken from all of our patients as sown in Tables 1 and 2.

Table 1 Main presenting symptoms of patientsTable 2 Socio-demographic data of included patients

Rectal examination for empty collapsed rectum with absent rectal ampulla, tight anal sphincter and impacted stools. Also, to exclude signs of enterocolitis. Investigations was done in the form of full laboratory investigations and radiological imaging in the form of plain abdominal X-ray films erect and supine and unprepared (unprepared to prevent transient dilatation of the aganglionic segment) single contrast enema were done to confirm the diagnosis by revealing the “transition zone” or the funnel shaped area between the narrowed aganglionic distal segment and the dilated ganglionic proximal segment, with special attention to the lateral views in contrast study for accurate assessment of the distal colorectal segment. Delayed X-ray film after 24 h if transition zone is not identified. If significant barium is still present in the colon, it increases the suspicion of Hirschsprung’s disease. Contrast injection was done under screen to inject a moderate amount of barium. Antero-posterior and lateral views usually taken immediately, and delayed films were taken 24 h later. Anorectal manometry was not routinely indicated, but rather obtained based on the patient’s medical history and underlying illness. Partial thickness rectal biopsy was done for all patients to confirm the diagnosis by the absence of ganglion cells in the diseased segment. These biopsies were taken under general anesthesia before the definitive procedure.

Operative procedures

Group “A” patients will be subjected to laparoscopic assisted transanal Swenson pullthrough operation according to the following steps: insertion of laparoscopic trocars with abdominal insufflation colon mobilization, and control of mesenteric vessels with monopolar or bipolar cautery in infants or the ultrasonic scalpel in older children.

A circular incision is made in the rectal mucosa 10 to 20 mm above the dentate line, mucosal edge above the incision are sutured with silk for traction. Dissection with Swenson technique for the stenotic segment. Excision of the stenotic segment with restoration of the bowel continuity.

Group “B” patients are subjected to complete transanal Swenson pull-through according to the following steps: a circular incision is made in the rectal mucosa 10 to 20 mm above the dentate line, mucosal edge above the incision are sutured with silk for traction. Dissection with Swenson technique for the stenotic segment. Excision of the stenotic segment with restoration of the bowel continuity.

Statistical analysis

The data obtained were analyzed using SPSS (statistical package for social science) version 19.0 (SPSS Inc., Chicago, IL) on IBM (International Business Machines Corporation, Armonk, NY) compatible computer.

Two types of statistics were done:

Descriptive statistics [e.g., percentage (%), mean (x) and standard deviation (SD)],

Analytic statistics: to compare between different groups.