TAKEDOWN COLOSTOMY w/ ENDORECTAL PULL THROUGH
Hirsprung’s DiseaseHirsprung’s Disease
Prepared by:Ibanez, Mikaela Camille TGroup 164BSN 141
Hirsprung’s Disease
Also known as Congenital Aganglionic Megacolon.
It is the congenital absence of or arrested development of parasympathetic ganglion cellsin the intestinal wall, usually in the distal colon.
The most common site affectedis the rectosigmoid colon (short segment disease), and the less common is the upper descending colon and possibly the transverse colon are affected (long segment disease).
I. PATIENT’S DATA
Name of Client: Jonathan A. Frederick
Age: 1 year old
Operation Perform: Takedown colostomy
Type of Surgery: Ellective (Major)
Surgeon: Dr. Delfin Cuajunco
Date of Operation/Case No.: February 27,2010 / 644233
Type of Anesthesia: General Anesthesia
Anesthesiologist: Dr. Erlinda Oracion
Definition of operation performed
Removal of the aganglionic portion of the
colon and rectum with the anastomosis of the
proximal normal colon to the distal rectum or anus.
II. ANATOMY / STRUCTURE / FUNCTION
Discussion of the anatomy involved
In pediatric patients with aganglionic
megacolon megacolon, the section of colon that is
resected can include a short segment of rectum
and/or colon or, less often, the entire colon. The
section represents a functional obstruction caused
by a lack of ganglion cells in the muscular layer.
Because the distal segment is unable to relax, it
does not permit the passage of feces. The problem
may be recognized soon after birth or in later
infancy.
Functions of organs / body parts involvedColon
The last part of the digestive system in most vertebrates; it extracts water and salt from solid wastes before they are eliminated from the body, and is the site in which flora-aided (largely bacteria) fermentation of unabsorbed material occurs. Unlike the small intestine, the colon does not play a major role in absorption of foods and nutrients. However, the colon does absorb water, potassium and some fat soluble vitamins.
Rectum
The last section of the digestive tract, extending from the colon to the anus, in which feces is stored for elimination from the body.
Functions of organs / body parts involved
Etiology of the disease
Hirschsprung's is caused by a failure of
neural crest cells to migrated from the neural crest
down the GI tract early in embryonic development,
usually completed by 12 weeks. The reason for this
failure in migration is not entirely known, however
are thought to have an immunologic origin.
Signs and symptoms
The following are the most common symptoms of Hirschsprung's disease. However, each individual may experience symptoms differently. Symptoms may include:
not having a bowel movement in the first 48 hours of life
gradual bloating of the abdomen
gradual onset of vomiting
fever
Signs and symptoms
Children who do not have early symptoms may also present the following:
constipation that becomes worse with time
loss of appetite
delayed growth
passing small, watery stools
Risk for infection
Risk for injury
Hypothermia
IntraoperativeRisk factors
RISK FACTORS
Anorectal achalasia
Constipation
Enterocolitis
Post operativeRisk factors
RISK FACTORS
III. PROCEDURE
Skin preparation
Abdominal
Begin just left of the midline for a left
paramedian incision; extend the prep from nipples
to the midthighs and down to the table at the sides.
If a colostomy is present, it is protected with a
separate sponge soaked in prep solution.
III. PROCEDURE
Skin preparation
Perineal
Begin at the pubic symphysis; extend the prep
to include the inner thighs, genitalia, exposed
buttocks, perineum, and anus (discarding each
sponge after prepping anus).
III. PROCEDURE
Draping
Combined Approach
A drape sheet is tucked under the patient’s
buttocks. The abdomen and perineal area are
draped with folded towels. Towels may be secured
by using a sterile, plastic adhesive drape, staples,
or sutures. A pediatric laparotomy sheet covers the
field. A colostomy stoma is covered with an
adherent plastic film.
III. PROCEDURE
Position
The child is placed in a modified lithotomy
position to provide access to the lower abdomen
and perineum. The legs may be held in position
using pediatric stirrups or abdominal dressing pads
and adhesive tape.
Anesthesia (technique used)
Inhalation given by mask
III. PROCEDUREIncision site
A left paramedian incision is made. The sigmoid colon is mobilized and superior hemorrhoidal vessels are divided, taking care not to injure the ureters and vas deferens. Frozen section of the colon muscle biopsies may be done at the level of the division of the bowel to make certain of the presence of ganglia. The pelvis is entered, the lateral rectal ligaments are cut, and the rectum is further mobilized, staying close to the bowel to avoid injury to the autonomic nerves.
III. PROCEDUREDiscuss the procedure
A left paramedian incision is made. The sigmoid colon is mobilized and superior hemorrhoidal vessels are divided, taking care not to injure the ureters and vas deferens. Frozen section of the colon muscle biopsies may be done at the level of the division of the bowel to make certain of the presence of ganglia. The pelvis is entered, the lateral rectal ligaments are cut, and the rectum is further mobilized, staying close to the bowel to avoid injury to the autonomic nerves.
III. PROCEDUREDiscuss the procedure
An operator from below (perineal field) may dilate the anal canal and then evert the rectal stump. A ring clamp or long Babcock forceps is inserted transanally, and a segment of the dissected proximal healthy colon is seized from within; with counter pressure from the pelvis, the colon is “pulled through” the anus. The anastomosis is then inverted, replacing it within the anal canal. The abdominal incision is closed.