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C HA PT ER

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IRSCH SPRUN G !SEASE :

I

SSISTE D

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EL UE S
•

Anne C. Kim and Daniel H. Teitelbaum

,
•
•

Step l : Su rgi cal A nato111)'

•

• + The end orectal pu ll-t hrot1gh procedu1·e essentially requires the removal of the rect al mucos
•
• and sub1nt1cosa to create an aganglionic cuff through \vhich norrnal ganglionic intestii1e is
brought through . In most cases, this can be performed as a prima ry or one-stage procedure
'.
•
avoid ing t he need for a leveling colostomy. Advantages of an endorectal dissection include
•
the avoida nce of t1·auma to sensory n erves i11 the rectun1 and preserva t ion of the int ernal
• j

•
• sphincter.
• • To have a complete understanding of t he s111·gical anat on1y, some consideration should be
given t o the hist ology of the colo11.
• A Underlying th e normal mucosa is a submucosal layer, which includes a muscular layer
and accompanying submucosal (Me issner) plexus; deep to t h is is yet another muscular
layer with its accompanying myent_eri_c (Auerbach) plexus. .
A In Hirschsprung disease, t he ganglia in both the submucosal and myenter1c plexuses are

absent for some length proximal to the dentate line.

A The exact relati on of the dentate line to t h e most distal extent of the agangl ionic segmen t
was init ially charact erized by A ldridge and CarnpbeH in 1968. They defined a "hypogan-
g1.1on1c
.
seg
ment" in wh ich ganglia we re sparse, bLtt still present , that exte11ded , on a\'erage
. . ,
•
for about 0.5 cm cranial to the den tate hne. I ndeed , th e lengt h of this segment was deter-
. df ch layer of the neu1·al plexus, f ro1n an average of 4 1nm for t h e n1yenteric
m ine or ea
for the deep mucous plext1s, an d 10 1nm for the s11perficial mucous plext1s.
p I exus, 7 mm

• 161
•
 , . 1 to t he dcnt ate l i ne sl1ou ld
• Therefore, suct i on rectal biopsies t aken about 2 cm cran ia h 1 vel of dissect ion from
0.5 cm proxi mal to the dentate line will ensure that t he entit e ag
removed · . d he internal sphi·n cter ar1·s1·n g as
• The muscular complex surrounding the anal canal inclu es .t . d 6 to 6.6 mm caudal
2

Therefore, the endo1·ectal mucosal dissection shou1cl continue to 5 . . . h. d'stanc

. . . . . mta1n1n t is I e,
the en e sph cte co1nplex is easily spared from ac1vertent d mage ' ecreas1ng e ris
tir 1n 11c in a
of ii1con tinence.

St ep 2: Preoperat ive Cor1siderat io11s

• Even in neonates, serial rectal wasl1ou ts shoL1ld be performed with I0 ml/kg of normal saline
accompan ied by digit al dilation . It shoulcl be emphasized that these are washouts, not
enemas. This requ ires tha t a large-bore catheter be pla ced above the aganglionic region and
left in place to allow the evacu ation of stool. The fluid for or the irrigation perforrned most
immed iately before the operation should also inclLtde 1°tb neomycin. In addition, parenteral
antibiotics covering both skin flora and enteric organisms should be .administered within a
half hour of initial incision as well as two doses postoperatively.
•

+ Older infants and children should also undergo a formal bowel preparation . Two days bef ore
surgery, a clear liquid diet should be initiated . On the day before surgery, a polyethylene
glycol (PEG -3500 molecu lar weight) oral solution should be given . Because children v\rit h
Hirschsprung disease cannot spontaneously evacuate stool, serial rectal washouts must b::-
performed every 4 to 6 hours on the day the PEG solution is administered.

Step 3: Operati,,e Steps

't)Sit ioning and Prepara tion

h Id b e pI aced i·n
+ A. nasogastric t. u. be is p.laced after induction of anesthesia · The pa· tI.ent s ou
litl1otomy position , wit h the buttocks brought to the edge of the t abl e d d
an proppe on a
k'
fol ded towel .. The legs sl1oul.d be carefully positioned on wooden s Is or e su arts wi t
I ·h
. . . . . . en an perineum s ou
be p repared with ant1sept1c
for access to th e anus and ent solLlt1on in standard fashion bef ore d · b h l
raping ot areas to al ovv
ir e abdomen. Alternativelv
. ,, in infa n ts, t h ent · body from the
u pper. abdomen to the feet may be prepped in t otal and feet and I e ire . .
1
(Fi·g. 19- 1) . on e may t h en h ave an assi.stant elevate bo' th legs du · egs P aced In stockinet te s
· h d . . h .
por tio n o·f t e proce ure. Once t he pa tient is prepped a Fol nng the transanal anas.t omosis
· h · bl dd r . . . ' ey cat eter should be inserted
into t e u rinary a er. Be1ore the 1nc1sron is made, the ent ire table sh .
• slight Tren delenburg position . ould be placed m a
•

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. ,. . 1 • 1r l c ) c r 1c.c 1J l1I 1;' s t 1t• I 're .

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l l'l l .
Il ( l I(
rxist i11g t:l)I C )Sl ()l l l)', i f 11rCSl'l1l .

- . . I ( 1 · i ·) l1c1wc I s I
1c1ws' ,111 ex t rem ely h y pcr·t roph i ecJ
• 111c cl <1ssi c a1111c n1·r\11c·c of 1l1c 11rL)x 1111l g;11 g l < ) ll c 1 . 't i'on zor 1c l1ct wecn agan -
111tlsctt l :.1r lt1ss <J I . 11· c1:· ' ) 9-2) T 1lC t ra11s1
\V \ ll , \V.it)1l1 .;\c l)c1v\'C I Lca11 I c 111a co
ite t 1\ ig. . ·. f . a] i n srcct i on ancl a seri es
.l . c , I" I '1 (' )J l l l )J ll:.111011 () V ISU
g 1
a11ll ga1 c Y' < II . . iLr·fJ ecl t he l1owe l shoul d
10 11c 1gl1t 11 1 111,t c 1 . ·i J
. . · • J' , ce s 1s 1c c '
ng dev
.a
I . I ··111sit io11 zcJ11c IC C'1 Ya
be t ra nsect ed w it h a st ap
li s st c11
i ceis rcco 1 le 11 ' -
01·c1·a11ial t o tl1is poi11t ). Tl1i )OVC
1n nicti ••
tl c'I })cca sc t hc. l evel of . agan
allyglion
wi l losis
hel pcan
to
I va ry a1·otllld t11c ci1•L t l lll fc1·c11cc l) r t IlC CC) Il1111 rl ll(.I r rocccd 1 r1g 111ore prohx11n h B t h th
enstl1·c t h 1t t he scl cct cc.l l)owcl w1. l l l1t vc css ") n t1·,,\ IIY 11L1t .m a I pat l1ology t . roug dou t . o cl e
p1·oxi111i1l bowel a11cl cl ist 1l bowel a1·c t l1cn m ol ·1· I 'th t h e la't t er cl1ssectc t o arou n 2
I I ZC ( , w i h d f h
t o 4 c111 abo,,e t11c pcrit o11eal re ncct1·011. ·rract1·.on su t Lt t·es arc t l1en pl aced at t c en o t e
proxin1al colo11ic seg1nc11t to facili t ate t l1e pull -th rough .

I Endorectal Dissect io11

•

+ Begin 11ing on the d istal bowel, a 2-cin scgmc11t j ust bel ow the level of the peri t oneal ren c
tion sl1ould be cleared of serosa , inesen tery, an<l pericolonic fat . The seromuscular layer
then inci sed by electrocau tery down t o t he leve l of th e submucosa. This incision is extend·
circui11ferentially using a hemostat . Dissecti on is ca rried f ttrt her using a Kitner to perf 01
blunt dissection , 01· in i11fan ts or n eonatal patien ts a cot ton-tipped applica tor can be ust.
effectively for this purpose (Fig. 19-3).
• Once establish ed , th is plane of dissection is cont i11t1ecl c.listally. U pward pu ll ing on the trac-
tion sutu res of the dist al 1·ectum is i1ecessa1-y to p rovide help ful countertract ion . A helpf u l
addition is the pl acemen t of ot l1er t1·act ion sutures in to each quad 1·a n t of the muscle cu ff ac;
t h e dissection p1·ogressi vel y develops (Fig. 19-4). With ou t the applica tion of this countert rac-
t i on , t h e dissect io11 beco m es in effect i ve, and one cann.ot 11roceed distally to an adequat e l eve l .
El cct1 ocau t ery should be used to coagu late la1·ger communicating vessels between the sub-
1111_1cosa an cl muscu l ar cu ff. The dissect ion should be carried out to within 0.5 cm of the
dcn t at c l i n e in neon at es and approximately 1 cm in older children.
+ Of ll Ole , t h i s d i ssect ion Can be carried OLlt Via a t ransanal approach, but if the d i ssection is
hegu n t ra n sabdomi nally, i t is most easily continued in this mann er to maintain t he proper
pl a n e. I n ad d i t i on , e m pl oyment of t he t ra nsabdomi nal approach mi n imizes the stret ch placed
on t h e a11al S}Jhincters by the ret ract o1·s requ irec.l to provid e exposu re. Once the d i ssect ion is
complet e, t he posteri or port i on of t he muscular cuff is spli t posteriorly and carried down as
.'
distally as possibl e, almost to t l1e same level as the en dorectal dissect ion .
••

., •
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 Ch opter 19 • • 1i rscl1sp ru ng Di sease: Soovc .:i n d Du h a m el ·rech n i qu es 1 65

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Figure 19-2

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Figure 19-3
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 A h. . d
• t t t s poin t , one Stlrgeo11tnoves t o tl1e perin eal field an 1aces ret ractors
. (phh ren ic, or anny-d
. h
P · erted into t e rectum, an
11avy ) at t he a11al verge. A ring forceps or Kel ly clan1p i s t en ins b I b
. . f h ucosal or su mucosa tu e
t h e ass stan t n t he abd ominal fielcl vvil l pl ace the en c1 o t e m d f h b
i i
i·nto t h e c Iam p. Eversion of th e cl issect ed segn1e11t i.s t h en per formecl , and t he en o t e tu e
is i·egrasped wi th a clan1p and 11el d i n t ract ion (Fi g. 19-5) .

A11asto1nosis

• An incision shott ld then be mad e on the anterior hal f of the mucosal or submucosal tube,
0.5 cm proximal to the dentate line . A Kelly clamp should be placed t hrough this opening
and used to grasp the t ract ion sutL1res on the proximal bowel (Fig. 19-6). Particular at tent ion
shot1ld be paid to avoid twisting the bowel as it is pulled through the muscular cuff. The
place 1ne11t of two di fferently colored sutu 1·es on the mesenteri c and anti-mesen teric sides of
tl1e ganglionic bow el will help t he su1·geon identify and correct any twisting that may occu r
during the pull-t h1·ough process.
• The anast o111osis is begun by incising the anterior half of the ganglionic colon and sutu ring
it to the ante1ior cuff of the anal mucosa using 4-0 polygla ctin suture. Su tures placed at each
corner and in n1idline are then used as traction sutures by the assistant as the surgeon p1aces
interru pted sutu res to com plete the anast omosis quadrant by quadrant .
+ The post erior portion of the anast on1osis should be completed by incising one quarter of the
remaining gangli on ic colon and everted mucosal or submu cosal segment .
+ Exposu re by the assistant is facilitated by outward traction place d on the sutures that ha\"'t:
been placed int o each quadrant .
+ The final quad rant of t11e anastomosis should be completed and inspected . The neo-rectum
can be inverted by applying gentle upwa rd traction on the colon. Rect al examination can
then be performed to palpa te the anastomosis 1.5 to 2 cm proximal to the anal \ erge. Af t er 1

a change of gloves, at tention should be redirected to the abdominal field.

+ The seromuscular port ion of the pulled-through segment can then be attached to the mus-
cular cuff to prevent early postoperative prolapse. N o drain is placed because significant
oozing is rarely seen .

Step 4: Post operat ive Care

• The nasogastric tube can typically be removed at the end of the operation. Care fallowing
the endorectal pull- through is that practiced for any patient who has undergone colon resec-
tion with a low anastomosis. It is advisable to allow no rectal examinations or medica tions
per rectun1 for at least 2 to 3 weks. .All attempts. should be made to provide postoperative
pain relief , as well as to normalize diet .a d .provde st?ol softeners as soon as possible. As
m en tioned previ ously, two doses of an t 1b1ot1cs 'vVl th skin and enteric flora co\·era ge should
be administered postoperatively. Follow-up and careful calibrat ion of the anast omosis
\vith Hegar dilators sh ould be perforr-ned at frequent clinic visits beginning at 3 \veeks
postoperatively.

.•

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Figure 19-5

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IC Jl 5: Pt ar l s an d Pi t fa l ls

• A gen era I way t o determ1.ne adequate mob1. J1.zat1. 011 o f· t 1lC })t.ox t·1n al cc1l c)11i c scg111cr 1t . i s l <)
4

stretch i.t over t he ptlbis t o t he anal verge. I f 11101·c 1cngt l 1 r.s ri c'e> d cd ' i t 1111y 1 )C . 1 le1fJ 1 Ll1 IIC1
d1' v1·de t he i·n1rer1· or mesen teric art ery n ear i.ts 01·1. g1.11, f Jt·csc t.\'I·n g t i le n a 1·gi11al a rt c r1;1I 11·(·1c '.
1" f
• Concern over t h e subseqt1e11t problc111s vv i t l1 st ooI cvacL1n t 1. 011 c.au sccl 1.,y t l.1c. JJ 1·cse 11cc L) ;. 111.
abn ormally functioning i11tcr11al ar1a l spl1inct er l1as l ed so1nc st1rgco11s lf) d r v i c) c 11.< Jl )fl l t l c
poste1·1· 01·wa ll o f t h e 1nt1scular ctt ff bu t also 1l1c c1·an1·a 1 11ort J·()J1 o f t he 1·n t c r·nn ' I sIJI11 n ct c r. r111s
appea rs t o cause few, i f any, p1·obl e111s w i t h con t i11c11cc. .
• As nie11t i o11ed , it is h el pf u l to tlse d i ffcrc11t col ored st1t u res on t l1c c11cl of t il e 11rox J J lln l , gat l-
glionic bovvel t o 111ai11t ai n it s oric11tal ion .
• Al t hough con1plete st1·ict u1·es of t h e an ast on1osis arc tt nco111r11011, t l1c anaston1osis shotJ l cl he
gent l)' sized vvith a Hega1· dilat or at cacl1 cli n i c visit . In ge11c1·n l , at t l1e in it i al vi si t (a}Jou t 3
weeks postope1·at ively), a neonat a l pul l-t h rough shott ld accept a size 7 to 9 I-I cga r. Su lJscqu cn t
visits should gradu ally increase tl1i s size to between 10 an cl 12.

Soave

St ep I : Surgical An at otn)'

See preceding Soave tech nique.

St ep 2: Preope ra t ive Considc1·at ions

+ Preoperative wasl1outs and, depen ding on the pa tient s age, bowel prepara tion are identical
to that for the endorectal pu ll-throt1gh, as detailed above. Use of p1·e operat ive ant ibiot ics is
the same as t hat with t he open endorectal pull-through . Ca1·e ful considerat i on should be
gi\'en t o posit ioning, for if the lowe1·ext1·emit ies a1·e t oo higl1, they will interfere with the
surgeons abil ity to manipu late the Iaparoscopic inst ru 1nents. It is oft en easier to prep the
entire lower half of the infant int o the opera ti\1e field , and l<eep the legs in a supine posit ion,
or hanging jus t off the bed, dt11·ing t he laparoscopic portion of the proce du re. One could
t hen have an assistan t elevate the I owe1·ext ren1ities once the surgeo11s are ready to perform
the perinea] portion of t he procedu re.
+ At t he beginning of t he case, tl1e sttrgeon generally stands 011 tl1e }Jatie11t 's right , while t he
assistant stands at the foot of the ope1·ating tabl e. Placement of the monit o1·on the Ieft of the
patien t near the foot of t he bed is opt imal (Fig. 19- 7).

• •
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Anesthesiologist

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Figure 19-7
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r /( ) SL'Ct ic. 11 I\ " • Ab( f on1er1

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•

Step 3: Ope rat i,e Steps 1

Incision

• An umbilical port sh ould be placed fi rst , followed by t roca rs i.n t h e ri·ght u pper quadran t ln i
the re1na ining one in the supra pubic area .

Leveling

• Before mobiliza t ion of the colon, it is necessary to determine the level of aganglionosis, which
begins by visually inspecting for a transition zone and taking a seromuscular biopsy just
above this level. This is most easily accomplished by grasping the serosa with the nondomi-
nant hand and sharply cuttir1g into the intestinal wall until the level of the submu cosa is
reached . One then proceeds to dissect the bovel bluntly in this plane until a 0.5-cm piece
of muscularis is obtained . If a perforation occurs, one can simply close this hole \vith an
intracorporea lly placed suture.
• If one cannot identify a transition zone , one should take the first biopsy just above the peri-
tonea l reflection and proceed proximally at abou t 10-cm intervals as needed. One should
also consider perfarming an appendectomy early in such a case, part icularly if specimens
continue to show absence of ganglia, as the child may have total colonic aganglionosis.
•

I
•
Dissection

+ Dissect_ion and Ie eling of the aganglion ic segment proceed as in the open technique, with
•• the assistant holding the can:era and the upper troca r grasping the rectum for exposure and
•
• •
retraction. Surgical clip applie rs may be used to ligate blood vessels, with small vessels con-
J
trolled by cautery (Fig. 19-8). Foll owing mobilization , the surgeon and assistant shoul d
j '
switch places. The transanal dissection , pu ll-through, and anast omosis then pro d h
.
deta1·1s o f w h'1ch are give . h h h cee
•
I
• I

n 1n t e c apter on t e t ransanal approach (see Chapter l S). , t e

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1 72 Seel it111 IV • ,\bcJ omen

• Postoperat ive care is as det ailccl i11 t he sect ion on cn dorectal pu l l -through .

Step 5: Pea rl s a11cl Pit fall

• Ideall}' t l1e lvVO \Vl1rl< i11g port s shott lcl e,1cl1l)C a ha 11c1,s W I·(Ilh away f ro m t h e. u m }1i l.i c..a l 1 1c > r l ,
r

ho\\:e,·cr, if t he in fcrit1r port is pl acrcl t oo low, t he mobi l i t y of t h e t rocar wi l l be I n t t e i b}

t l1e lo\ver cxt rc111i t ics and il iac crest . A11 i c.l eal wa y t o assess wt1et h er one has ach r e\ e<l '1<l e-
quate mobil izat ion of t l1c ga11glion ic bowe l is t o con f l rn1 t ha t i t can e ea i l y be pu l l ed <l o,v n
t o t he l o\\·est .,or t ion of t l1c pel vi s be fore })egi11n i n g t h e t ran sanal dr ssect1o n . .
• I t is also import an t t o 111ark caref u l ly t he t ra nsit ion zone of t h e col on wi h a su tu re .cl u n ng
tl1e laparoscopic portion of t l1c case to allo'vv for easy con fi rma t ion of th is leve l d un n g t he
tra nsanal port ion of t he proced u re .

Duhamel Pull-Through

Step I : Surgical A11at omy

•

+ The Duhamel t echnique was advanced in 1956 to avoid the tedious pelvic dissection of the
Swenson procedure and to protect t he nervi erigent es, \vhich may be found lat eral and ante-
rior t o the rect um . The proced t1re has undergone several modifications, the most import ant
of which was by Mart in, and included the t1se of an au t oma tic stapl ing de\ice. It is fa i rl} 1

stra ight forwa rd and continues to be popu lar today. Despi t e its relati\ e si111plicit)r, se\·eral ke)·
1

technical poin ts must be fallowed .

+ As with other pu ll-t hrough procedtt res, gangl ionic bowe l is brot1gh t do\\'11 to less than 1 cn1
proxi ma l t o t he dent ate l ine. To preserve the aL1t onomic nen·e ple;i.... 1s t o the ge11itot1rinaf)'
system, ve ry lit t le manipu lation of the rect u n1 is pe rforn1ed anteriorly.
+ In the past , the child often had a leveling colostomy, vvh icl1was placed se\'eral mont hs pre\'i -
ously. This served to decom press the bowe l a11cl ret u rn i t to no1mal calibe r. The ope rat ion
was generally perfarmed when tl1e chilcl was 6 to 12 inon t l1s of age \vi th a \\'eigh t of 1o kg.
With the use of smaller endo-stapling devices, the proced L1re can also be per forn1ed prima rily·
in the newborn period.

Step 2: Preopera t ive Considerat i ons

• The child is admitted t he day bef ore the su rgery for a mechani cal bowel preparat i on as \\·ell
as oral ant ibi ot ics. Care must be taken to give adequ ate rectal and colonic wasl1out s because
st ool is oft en i nspissat ed in the distal rect um. It is necessary to do a rectal exa m inat ion on
the child be fore the pull -th rough to ensure t l-iat no resid ual stool is present . Preo pe rat i\·e
ant ibiotics should be gi,1en .
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pt u ng D1sc,1se: Souve tl t1ci Dl 1J1,1m el Tecl1ni (f U CS •

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• A nasogast ric tube i plac a f . . . .

position , and the pa t ien t . e u t er incl tCtll' n of ar1cst hcsia. Th e cl1i l,J is p1ac·cd i11a su pi n e
1
nettes aie placed around ,s P pared circu n1fercn t iallr fron1 1 h e ahcl on1cn 10 t he ket. St ocki -
pat ient has beeii. prepa ., ac d 00.1• antl a Foley cat heter is i nserted in10 1hc blatldcr aft er t he
ing and flt.J\ing t he 1 l c :1n dr t ed · Excellen t cx11ost1re is olJt ai11rd lJy ass ista11Ls su pport -
. . d tt r1.11g t h e ::i11al nn Jst ornosis. A l te rnat i vel y,
t h e ch i ld can ·be })l O\Vc r ext rem1t1es 'lt tl 111ps
d l . le
ac n st1rrtt i1s or on sk is.
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. Incision

• A l1ocke)y stick or obliq t1e incision is made ro incorporat e t he colost omy, if presen t .

Leveling

• The transit ion zone betvvee n aganglion ic and ganglionic bovvel can be made b)·a combinat ion
of visual inspection and a series of frozen sect ions. On ce t he presence of normal ganglion
cel ls is ident ified , t l1e bowel shot1ld be t ransect ed \vit h a stapl ing de\·ice abo\ e t he transit ion 1

zone (ideally approxi mat ely 5 cm proximal or c1·a nial t o t l1is poi nt ) t o enstt re t hat t he remain-
ing bowel will have essen t ially normal i.11.11erva t i on. Bot t he proxi111al bowel and distal bo\ve l
are then mobili zed , with the lat ter mob1l1zed t o approximately 2 to 4 c111 abo\·e t he peritoneal
reflection. Tract ion su tu res are then pl aced a t t he e11d of t he proximal colonic segn1ent to
facilitat e the pu ll-t hrough.

Retrorect al Dissection

. . h post erior midline is used to creat e a ret rorect al space down to the
• Blu nt dissecti on_ 1 t e Dissect ion is considered complet e once an assistan t 's finger, insert ed
level of the pel\TJ C . oor. h an us can be palpated f rom the abd on1inal field. While a blu 11t
onIY 1 to 1·5 cm intdo. t e t ion a'n in dex finger can easily be Lt sed to develop this plane.
• clam p may help t h_e ts eche rtrorectal dissect ion , t he aga nglion ic bowel is t ransect ed wit h
• Following com pl enon foht erit oneal reflect ion . Tacki ng su t ures are placed on each edge of
a sL apler at the level - t e p terior retraction of tl1is seg1ne11t du ring t he pu ll -t l1rough .
1·
the st ap I e i n e t 0 fac1l1tate antin sttt ures shou l d be used t o n1ark the mesen teric and ant imes-
•

1
• Polypropylene and polyg at ic bowel This \Vi ii hel p t he su rgeon Lo main tain the orien t ation
en teric surfaces of t h e gang i on h .
of t he bo\\'Cl as it is ptt l led th rottg . •

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an <l place narrow anal ret ract ors to be h eld by assistants in t u ld be t reated ;i ami-
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n at ed , there is no n eed t o n1ain t ai n a sepa rate stenle fi eld wit P '
gloves sh ou l d be changed once t he anast o1nosis is crea ted . . II f t he rect u n 1 C 5 cm
• 1
tained by cu rvin g t h e i ncision appropriately when extended i n eac . ct1on . .
1
. cision are res ect ive '
•
marked with undyed and dyed polygl act i n sut u res. These sut u res ar place. . 111 t e m i ine ,
and \Vi t h one on each edge; h e1n ostats are used to h old each sutu re in posit ion .
• Fro1n the pe ri nea!field , a long cla1np is inserted in to t he ret rorecta l space nd to\vard t he
• abd ominal field. The clam p is used to grasp the tacking sut u res on t he distal gan hon 1c
bo\vel , and t he surgeon in t h e abdomi nal field gu i des t he bowel to help preven t rotati on of
,
tl1e bo\vel as it is pulled t hrougl1 (Fig. 19-9).
..
• •
• The staple line is tl1en excised on t he anterior h alf of the ganglionic colon , and a single- l a;'ered
•
•

•
anastomosis is begu n using the three previously placed polyglactin sutu res. Each stitch should
be carefu lly placed to enst1re that the anterior wall of the anus is not incorporat ed in to an 7·
•
• of t he sutures.
•

Anastomosis

• Afte.1· completing the anterior hal f of the anastomosis , th e remai·n d er of the t I 1· .

excised , and the anastomosis is completed. s ap e ine 1s
• One arm of an au tomatic stapling device is placed into the nativ
•

•
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•

ferred ; a smaller en do-stapler is used in newborns. P t ng device is generally pre-

• It is common for a single staple appl ication to b · ffi ·
•

. of ganglionic and aganglion ic e insu c1en t to I

•
t h e anastomo Fi comp t.e t he fu ll len gt h of
sis bowe l ( _1 e
by finng the stapler from the abdominal field Th 19
lg. . 0, B)
· e stap e line f h · This can be remedied
opene d , an d a small en terotomy is made in t he gang .ionic . col 0 t e aganglionic rect Ltm is
l 1 at a similar Ie\,el t , ,,II -
• • .p acement
. of a reloaded stapler. The anastomosis. must be d · . on II 1 O\\ C. l

It Is complete. Huge fecalomas can 10c rm l·r a b rid igita Y examined to en SL l"L" t h at
1

segments. ge or spu r remains betwee 11 11l \\'e1

•T h
I e open C ed .staple line is then sutu red t o t h. e ent erot om .
ayers. re t aken not to leave a blind y the ganglion1·c I .
a is d'
-en ing stump f in co on 111 [ \\r o
cou ld lead t o t h e development. of a large fecal o agangl ionic bo\\' I b .
•• tonea lized , an d t he abdomen s c1osed Th oma. The neorectum ma)" or e ecause t l11s
•
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end of the proc ed ure. . e nasogast ric tu be typica ll ' may not be reperi -
•
} can be remo\'ed at t he
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St ep -f.. Post(l11cra t i\ c Steps 1

• Postoperat i,·e care is as detailed in the sect ion on endorectaI pu 11- through ' except that dila-
•
t ion \\'it h Hegars may not be necessary.

• •

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Step
. .5. Pearls and Jlil fall s
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.. As men tioned previously, it is of paramount importance to ensure completion of the anas-
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tomosis bet\:veen the aganglionic and ganglionic portions of the bowel.
•
• • • Care must be tal<e n to ensure that there is no twisting of the pulled-through segment ; as
••
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Bibliograph) 1
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. • ..i\ldridge RT, Campbell PE. Ganguon cell distribution in the n ormal rectum and anal canal· b · f . . .
.. ..•. ."' . •
· disease by anorectal biopsy. j Pedi ar r Su rg 1968;3:475-490. · a asis or the diagnosis of H1rschsprung's
• . Teitelbaum DH . Coran AG . Hirschsprung disease, operations. In Spitz L, Coran AG d . . .
•
• Hodder Headline Group, 2006; pp. 553-563. 0
' e s. p erative p cd 1at 11c su rge1) 6th ed. London: 1•
• •
• Teitelba um DH , Coran AG. Hirschsprungs disease and related neuromuscular disord f h . .
•
• •
alsrud E\i\ Coran AG, eds. Pediat ric surge ry , 6th ed . Philadelphia ·Mosby Elsevi ers t e intestine. ln Grosfeld J L, O'Neil JA Fonl<- °
•• • • . er, 2006; pp. 1514- 1547. '
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