TAKEDOWN COLOSTOMY w/

ENDORECTAL PULL THROUGH

Hirsprung’s Disease

Prepared by:
Ibanez, Mikaela Camille T
Group 164
BSN 141
 Hirsprung’s Disease

 Also known as Congenital

Aganglionic Megacolon.

 It is the congenital absence

of or arrested development of
parasympathetic ganglion cells
in the intestinal wall, usually in
the distal colon.

 The most common site affected

is 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
 II. ANATOMY / STRUCTURE / FUNCTION
 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.
 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 involved
Colon
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 FACTORS

Hypothermia

Intraoperative
Risk factors Risk for injury

Risk for infection

RISK FACTORS

Enterocolitis

Post operative
Constipation
Risk factors

Anorectal achalasia
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. PROCEDURE
 Incision 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. PROCEDURE
 Discuss 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. PROCEDURE
 Discuss 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.