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.