NOTES for Surgical Treatment of Long-Segment Hirschsprung's Disease: Report of Three Cases

Purpose: The aim of this study was to evaluate the feasibility of natural orifice translumenal endoscopic surgery (NOTES (R); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) for the surgical management of long-segment Hirschsprung's disease. Patients and Methods: Three children with long-segment Hirschsprung's disease were enrolled in this study. In all three cases the transition zone was proximal to the splenic flexure, with too long a segment of distal aganglionic colon to perform an isolated transanal pull-through. Our procedure was as follows. A rectal mucosectomy was performed starting 0.5 cm proximal to the dentate line and extending proximally to the level of the intraperitoneal rectum. Three cannulas were inserted through the muscular sleeve into the abdominal cavity. The mesocolon, lateral peritoneum, and greater omentum were ligated and divided in order to mobilize the colon. After mobilization, the aganglionic distal bowel segment was pulled through the anus and resected. Finally the colo-anal anastomosis was created. Results: All three operations were successfully performed without intraoperative complications. No additional ports or conversion to an open procedure was required. The operative times were 242, 195, and 174 minutes, respectively. All three children were discharged without complication with follow-up for at least 1 year. One year after the procedure the 3 patients were stooling one to three times per day, with no fecal soiling or constipation. Conclusions: This NOTES procedure may be a safe and feasible option for the surgical treatment of longsegment Hirschsprung's disease.