Comparison of Surgical Approaches for Hirschsprung's Disease: A Network Meta-Analysis

Hirschsprung's disease can be treated using multiple procedures, including Soave, Swenson, and Duhamel techniques, performed via open, laparoscopic, transanal, or robotic approaches. However, the optimal surgical approaches remain controversial, particularly regarding perioperative efficiency and long-term bowel function. We performed a network meta-analysis to compare these approaches.

A comprehensive literature search was conducted according to PRISMA guidelines across electronic databases, including PubMed, Embase, and the Cochrane Library, from inception until the last update on October 31, 2025. Nine techniques (open, laparoscopic, transanal Soave and Swenson; open, laparoscopic Duhamel; and robotic-assisted procedures) were included. Primary outcomes were operative time, length of stay, and blood loss; secondary outcomes were postoperative Hirschsprung-associated enterocolitis (HAEC), constipation, and fecal incontinence. A random-effects frequentist network meta-analysis was conducted using MetaInsight to obtain the ranking probabilities.

Twenty-eight studies, including 1,911 patients, were included. For perioperative outcomes, Transanal Swenson (TSw) had the shortest operative time, followed by Transanal Soave (TS) and Laparoscopic Swenson (LSw), whereas Open/ Laparoscopic Duhamel and robotic-assisted procedures required longer times. LSw ranked best for length of stay, and Robotic-assisted surgery was associated with shorter hospitalization compared with most open techniques. Robotic-assisted surgery showed the lowest intraoperative blood loss and was statistically superior to the other approaches. No significant differences were observed in postoperative HAEC, constipation, or incontinence; bowel function outcomes were comparable across techniques.

This is the first network meta-analysis to comprehensively compare all major surgical approaches, suggesting that the choice of surgical approach for Hirschsprung's disease mainly affects perioperative efficiency rather than long-term bowel function. Minimally invasive and transanal procedures offer advantages in operative time and hospitalization, and robotic surgery minimizes blood loss. No significant differences were identified in postoperative HAEC, constipation, or incontinence. These findings may guide surgical planning in consideration of perioperative care.