Laparoscopic Help May Ease Soave Surgery Outcomes in Older Toddlers

For children born with Hirschsprung disease, the missing nerve cells in part of the colon mean that waste simply cannot move through the bowel the way it should. Surgeons can fix the anatomy, but the question of how best to fix it has divided pediatric operating rooms for decades. A new retrospective study from Qilu Hospital of Shandong University in Jinan, China, now adds an intriguing twist to that debate: the surgical approach that works well for a baby may not be the one that works best for a toddler, and age itself may quietly shape the calculus of risk.

The research, published in BMC Pediatrics, examined 188 children aged four years or younger who underwent a primary Soave pull-through procedure, the standard operation for Hirschsprung disease. In this procedure, surgeons remove the aganglionic segment of bowel that lacks nerve cells and pull healthy colon down through the rectum to reconnect the digestive tract. Two main techniques exist for accomplishing this. The purely transanal Soave approach reaches the bowel entirely through the anus, leaving no abdominal incisions at all. The laparoscopic-assisted Soave adds small keyhole incisions through which a camera and instruments help mobilize the colon from the inside of the abdomen before the transanal dissection begins.

Whether one of these approaches outperforms the other has remained uncertain, particularly because most comparative studies have lumped children of very different ages together. The Chinese team, led by Jichang Han and Zeyong Niu, took a different tack. They stratified their cohort by age, separating children younger than 24 months from those aged 24 to 48 months, and then compared outcomes between the two surgical approaches within each age band. The primary outcome was the occurrence of at least one postoperative complication within 12 months of surgery, a measure that captures the range of problems from wound infections to bowel obstructions that can follow this operation.

The results revealed a striking asymmetry. Among children younger than 24 months, the complication rate was 11.7 percent in the laparoscopic-assisted group and 14.5 percent in the purely transanal group, a difference so small that adjusted statistical analysis found no meaningful advantage for either approach. The adjusted odds ratio came out at 0.92 with a confidence interval spanning well past the line of significance, and the P value of 0.893 confirmed that the two techniques performed essentially identically in this youngest age band.

But among children aged 24 to 48 months, the picture changed dramatically. The complication rate was 8.1 percent in the laparoscopic-assisted group compared with 33.3 percent in the purely transanal group. The adjusted odds ratio of 0.18 with a confidence interval of 0.04 to 0.76 and a P value of 0.019 suggested that laparoscopic assistance was associated with a substantially lower risk of complications in this older age band. In other words, the purely transanal approach, which had performed just as well as laparoscopic assistance in infants, appeared to carry more than four times the complication risk in toddlers.

Yet the study’s authors were careful not to overstate their finding. When they formally tested whether the effect of surgical approach depended on age by including an interaction term in their regression models, the result did not reach statistical significance. The P value for the interaction was 0.082, tantalizingly close to the conventional threshold but not crossing it. This means that while the raw data showed a clear difference between age groups in how the two approaches performed, the formal statistical test could not conclusively establish an age-dependent benefit for laparoscopic assistance. The finding remains suggestive rather than proven.

The study also uncovered differences in operative metrics that held true across both age groups. Laparoscopic assistance was associated with a longer total operative time, reflecting the additional setup and abdominal work that the keyhole approach requires. But it was also associated with a substantially shorter anal operative time, the portion of the procedure performed through the anus. This makes anatomical sense: when the colon has already been mobilized laparoscopically from above, less dissection remains to be done from below. Postoperative hospital stay was shorter with laparoscopic assistance in the 24 to 48 month group, although the interaction by age for this outcome was also not statistically significant.

One of the more technically sophisticated aspects of the study was its handling of sparse-event bias, a statistical pitfall that arises when the number of complications is small relative to the sample size. With only a handful of events in some subgroups, conventional logistic regression can produce unstable or misleading estimates. The researchers addressed this by performing a sensitivity analysis using Firth penalized logistic regression, a method that applies a penalty term to stabilize estimates when events are rare. The Firth analyses yielded broadly consistent estimates and did not materially change the interaction results, lending additional confidence to the primary findings.

The regression models also adjusted for a comprehensive set of measured demographic, clinical, anatomical, and calendar-era factors, including heteroskedasticity-consistent covariance estimators to account for potential variability in the data. This level of methodological care reflects a growing awareness in pediatric surgical research that retrospective comparisons can be confounded by differences in patient characteristics, disease anatomy, bowel dilatation, and the era in which surgery was performed, all of which may influence both the choice of approach and the likelihood of complications.

The practical message from the study is ultimately one of individualization rather than dogma. The authors conclude that surgical approach should be tailored according to disease anatomy, bowel dilatation, anticipated operative complexity, and the overall clinical context rather than age alone. For a baby with a short aganglionic segment and minimal bowel dilatation, the purely transanal approach may be just as safe as laparoscopic assistance and avoids abdominal incisions entirely. For a toddler with a more dilated proximal bowel and a more complex anatomy, the laparoscopic approach may offer meaningful advantages in reducing complications and shortening recovery. The study does not settle the debate, but it sharpens it, suggesting that the answer to which operation is best may depend less on the calendar age of the child than on the specific anatomy and clinical circumstances that each patient brings to the operating room.

Subject of Research: Laparoscopic−assisted versus purely transanal Soave procedures for Hirschsprung disease in children aged ≤ 4 years: an age−stratified retrospective study

Article Title: Laparoscopic−assisted versus purely transanal Soave procedures for Hirschsprung disease in children aged ≤ 4 years: an age−stratified retrospective study

Article References: Han, J., Niu, Z., Mou, Y., Wang, D., Zhou, Y., Ding, Y., Xin, P., Song, G., Li, A., & Wang, J. (2026). Laparoscopic−assisted versus purely transanal Soave procedures for Hirschsprung disease in children aged ≤ 4 years: an age−stratified retrospective study. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07872-6

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07872-6

Keywords: Laparoscopic, assisted, versus, purely, transanal, Soave, procedures, Hirschsprung, disease, children, aged, years