Hirschsprung Disease - Approach & ManagementVikas V
Hirschsprung Disease. - A developmental Disorder of Intrinsic Component of Enteric Nervous System.
Also known Congenital Megacolon.
This Presentation deals with The eitology, presentation, diagnosis, medical and surgical management & complications of the same.
OPEN RIGHT HEMICOLECTOMY- STEP BY STEP OPERATIVE SURGERY
#surgicaleducator #operativesurgery #openrighthemicolectomy #usmle #babysurgeon #surgicaltutor
Subscription Link: http://youtube.com/c/surgicaleducator...
Surgical Educator Android App link: https://play.google.com/store/apps/de...
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• In this video today, I have discussed Open Right Hemicolectomy .
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch all my teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
LAPAROSCOPIC CHOLECYSTECTOMY- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #laparoscopiccholecystectomy #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and Open Cholecystectomy.
• In this video today, I have discussed Laparoscopic Cholecystectomy- the flagship procedure for laparoscopic surgeries.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and the links are:
• https://www.youtube.com/watch?v=VStEzI1jL8Y
• https://www.youtube.com/watch?v=O8j4kwpzd24
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
Hirschsprung Disease - Approach & ManagementVikas V
Hirschsprung Disease. - A developmental Disorder of Intrinsic Component of Enteric Nervous System.
Also known Congenital Megacolon.
This Presentation deals with The eitology, presentation, diagnosis, medical and surgical management & complications of the same.
OPEN RIGHT HEMICOLECTOMY- STEP BY STEP OPERATIVE SURGERY
#surgicaleducator #operativesurgery #openrighthemicolectomy #usmle #babysurgeon #surgicaltutor
Subscription Link: http://youtube.com/c/surgicaleducator...
Surgical Educator Android App link: https://play.google.com/store/apps/de...
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• In this video today, I have discussed Open Right Hemicolectomy .
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch all my teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
LAPAROSCOPIC CHOLECYSTECTOMY- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #laparoscopiccholecystectomy #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and Open Cholecystectomy.
• In this video today, I have discussed Laparoscopic Cholecystectomy- the flagship procedure for laparoscopic surgeries.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and the links are:
• https://www.youtube.com/watch?v=VStEzI1jL8Y
• https://www.youtube.com/watch?v=O8j4kwpzd24
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
OPEN INGUINAL HERNIA REPAIR- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #openinguinalherniarepair #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and open and
Laparoscopic Cholecystectomy
• In this video today, I have discussed Open Inguinal Hernia Repair.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Ventral hernia is protrusion of peritoneal sac through anterior abdominal wall defects except Groin hernias. In this presentation I have discussed Epigastric, Umbilical, Para umbilical, Incisional, Spigelian and Lumbar hernias.
Normally, fistula is defined as an abnormal communication between two epithelized surface.But enterocutaneous fistula is an abnormal communication between the skin with various parts of the gut. The ileum is the most common site of origin of enterocutaneous fistula.
OPEN INGUINAL HERNIA REPAIR- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #openinguinalherniarepair #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and open and
Laparoscopic Cholecystectomy
• In this video today, I have discussed Open Inguinal Hernia Repair.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Ventral hernia is protrusion of peritoneal sac through anterior abdominal wall defects except Groin hernias. In this presentation I have discussed Epigastric, Umbilical, Para umbilical, Incisional, Spigelian and Lumbar hernias.
Normally, fistula is defined as an abnormal communication between two epithelized surface.But enterocutaneous fistula is an abnormal communication between the skin with various parts of the gut. The ileum is the most common site of origin of enterocutaneous fistula.
Approximately 75% of abdominal wall hernias occur in the groin.
The lifetime risk of inguinal hernia is 27% in men and 3% in women.
And hence Of inguinal hernia repairs, 90% are performed in men, and 10% are performed in women.
The incidence of inguinal hernia in men has a distribution, with peaks before the first year of life and after age 40.
Indirect inguinal and femoral hernias occur more commonly on the right side.
This is attributed to a delay in atrophy of the processus vaginalis after the normal slower descent of the right testis to the scrotum during fetal development.
The predominance of right-sided femoral hernias is thought to be caused by the tamponading effect of the sigmoid colon on the left femoral canal
The prevalence of hernias increases and the likelihood of strangulation and need for hospitalization increase with aging.
Component separation technique for a very large abdominal wall herniaSanjiv Haribhakti
Component separation technique is an excellent technique for large ventral central defects which can allow a medial shift of approx. For More information visit at Gisurgery.info
Laparoscopic sterilization was the first popular minimal access surgical procedure ever performed. Laparoscopic sterilization is very straightforward procedure. Worldwide laparoscopic sterilization is now the most commonly applied method for family planning
Laparoscopy is an innovative diagnostic and surgical tool in veterinary field. Laparoscopic surgeries revolutionizes the minimally invasive surgical approaches with less surgical trauma and faster recovery.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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4. The three loops of the external anal sphincter. Continence
depends on the preservation of at least one of the three. Some
subcutaneous muscle fibers encircle the anus; some attach to the
perianal skin anteriorly at C.
5. Diagram of the extrinsic muscles of the surgical anal canal. (1) Coccyx; (2) pubis; (3)
levator ani muscle; (4) puborectalis muscle; (5) deep external sphincter; (6) superfi
cial external sphincter; (7) subcutaneous external sphincter; (8) anococcygeal
ligament; (9) anal verge; (10) rectum.
6. The interior of the anal canal showing the rectal columns, anal valves, and anal
sinuses (crypts). They form the pectinate line
The pectinate line is the most important landmark in the anal canal. It marks the transition
between the visceral area above and the somatic area below. The arterial supply, the
venous and lymphatic drainage, the nerve supply, and the character of the lining all change
at or very near the pectinate line
9. Surgical interventions – Historical Perspective
Drs. Swenson,
Neuhauser
(a radiologist)
and Pickett Boston
1948 Recognized an area of spasm in the rectum or
Rectosigmoid that defined the site of obstruction in
patients with congenital megacolon using a barium
enema and fluoroscopy
Swenson & Bill 1948 First successful operative procedure.
The operation was undertaken based on careful
clinical observations and thoughtful deduction
ignoring the controversy at the time regarding the
influence of bowel innervation and
the presence or absence of ganglion cells in this
disorder
State (Minneapolis,
Minnesota)
1952 Described low anterior resection
Sandegard 1953 Reported the first successful operation in a patient with
total colonic aganglionosis (TCA) by performing a total
colectomy and an ileoanal anastomosis
Bernard Duhamel
(St Denis, France.)
1956 Described the retrorectal transanal pull-though
procedure.
10. Surgical interventions – Historical Perspective
Rehbein
(Bremen, Germany)
1958 Low anterior resection taking the anastomosis
down to 3–4 cm above the pectinate line
Grob
(Zurich, Switzerland)
1959 Used a different location for the posterior incision. He
made the incision 2.0–2.5 cm above the pectinate line.
Pagès in Paris &
Duhamel
1960 Rectal incision 1.5 cm above the pectinate line to avoid
incontinence and constipation
Soave of Genoa, Italy 1963 Described the endorectal pull-through procedure
Boley
(New York).
1964 Modified the procedure by performing a primary
anastomosis at the time of the pull-through procedure
Martin 1968 Described a modification of the Duhamel procedure
utilizing a side-to-side anastomosis between normally
innervated small bowel and aganglionic colon upto the
level of splenic flexure for TCA
11. Surgical interventions – Historical Perspective
Kimura 1981 used an aganglionic right colon patch.
Boley 1984 Left colon as patch
So et al 1981 First to report a one-stage pull-through procedure in
neonates with HD without a preliminary colostomy
Ziegler 1987 described the concept of myotomy/myectomy of
aganglionic bowel for patients with near total
aganglionosis (NTAG) with less than 40 cm of normally
innervated small bowel
Georgeson et al 1995 Described a laparoscopically assisted Soave endorectal
pull-through procedure avoiding an open laparotomy
De la Torre-
Mondregon &
Ortega-Salgado of
Mexico
1998 First to perform a one-stage totally transanal pull-
through procedure
12. Surgeries available for Hirschsprungs
Disease
• Rectal Biopsy –submucosal , full-thickness
• Colostomy , Ileostomy
• Definitive surgeries
-Swenson’s procedure
-Duhamel’s procedure
-Soave’s procedure
-Rehbein, State – outdated
14. Rectal suction biopsy
• Less than 4 years of age
• May be performed in ward or clinic without anaesthesia
• Painless if taken 2.5 cm above anal verge in neonate and
3.5 cm in older child
• Preoperative care
– Gentle bowel washout with 10ml/kg of warm saline
– Vitamin k in neonates
• Original suction biopsy instrument was devised by Helen
Noblett in 1969
• Variants: Solo-RBT, rbi2
• Blunt ended tube with a 3mm side hole 2 cm from the
tip
• Lithotomy position for infants
• Left lateral knees bent position for older children
15. • Lubricated instrument inserted into the
anus and side hole positioned at 3 cm from
anal verge
• This is the minimum distance and avoids the
normal hypoganglionic zone and diagnostic
confusion
• Side hole should face posterior wall or
lateral wall of rectum
• Suction applied by withdrawing the syringe
attached to the suction biopsy instrument to
3-5ml (~150cmH2O)
• After 2-3 seconds the knife is triggered
16.
17.
18. • Syringe suction is released to neutral pressure
before removing from the patient.
• Instrument is withdrawn and specimen removed
• 3X1mm
• Submucosa- whitish layer
• Procedure repeated at 3.5cm and 4cm above the
anal verge
• 2-4 specimens are collected
• Specimens marked with the level of collection
19. Postoperative care
• A rectal examination should be carried out after
completing the biopsy to exclude active bleeding.
• Observations should be continued for at least 2
hours, to ensure complete hemostasis.
Complications
• Inadequate specimen retrieval. 10 and 20 %
• Perforation.
• Bleeding.
• Pelvic sepsis.
20. • Solo RBT
*Solo-RBT: A New Instrument for Rectal Suction Biopsies in the
Diagnosis of Hirschsprung’s Disease, A. Pini Prato, G. Martucciello, and V.
Jasonni Genova, Italy. Journal of Pediatric Surgery, Vol 36, No 9 (September),
2001: pp 1364-1366
21. • Open rectal biopsy under general anesthesia is required when the
specimen obtained with the RSB instrument is inadequate or the child is
older.
• Preoperative preparation: Rectum irrigated with saline or very dilute
povidone-iodine solution.
• Position: The infant is held in the lithotomy position while an older child
will need to be placed in stirrups in the lithotomy position.
• Prophylactic antibiotics are given.
Open rectal biopsy
Procedure
■ The anal orifice is digitally dilated. It
is held open either with a Parks’
retractor (or similar self-retaining
retractor) or by an assistant holding
two small Langenbeck’s retractors.
22. • The superior aspect of the
dentate line is identified and
marked with a polyglactin
suture (3/0), which is used for
traction.
• Two additional polyglactin
sutures are placed on the
posterior wall of the rectum at
1 and 2 cm proximal to the
dentate line.
• Retain the needle on the most
cephalad of these sutures, as
it can be used to begin the
closure of the defect after the
biopsy is obtained.
23. • hold the middle suture.
• Using sharp curved scissors,
a full-thickness incision is
made along the lower half of
the rectal wall, between the
dentate line and the middle
suture.
• The rectal defect is closed in
a single, full thickness
running or interrupted layer
with an absorbable suture
(e.g. 4/0 polyglactin (Vicryl)
24. • Hemostasis may be
achieved with bipolar
diathermy or, more
usually, by suturing the
defect with a running
locking suture from
above.
• Complications
– Hemorrhage
– Infection
25. New born with
delayed passage of
meconium
Enterocolitis
Older infants/children
with constipation
(+or-)Rectal biopsy
(suction/full thickness)
Urgent decompression by
rectal irrigation +/_
colostomy
Fluid resuscitation
NG aspiration
Antibiotics
Plain X ray
Contrast enema
Primary pull through
Leveling colostomy
R. Transverse colostomy
Three stage procedure
Two stage procedure
Frozen section facility
Anorectal
manometry
for RAIR
(screening)
26. Three stage procedure
• Advantages
– Colostomy can be made even if transition is not evident & frozen
section facility is not available
– Anal anastomosis is well protected by colostomy
– The risk of the error of opening the colostomy in an aganglionic area is
much reduced
• Disadvantages
– Multiple admissions & operations
– Molibilisation of colostomy is needed in cases with long segment HD
– Distal segment may undergo disuse atrophy if left long or child lost for
follow-up
• May not function properly after colostomy closure
27. Two stage procedure
• Initial colostomy is performed at the junction
of the ganglionic & aganglionic colon (Leveling
colostomy)
• Second stage – pull-through done after taking
down the stoma & using the proximal end for
pull-through
– 6 – 12 months age
28. Levelling Colostomy
Indications
• Severe enterocolitis
• Markedly dilated proximal colon due to delayed
diagnosis
Advantages
• Allows determination of aganglionic level- facilitating
subsequent pull- through
• Allows the proximal bowel to grow
• Colostomy closed during pull-through thus avoiding a
3rd operation
• Max. amount of colon for absorption
• Assures colostomy is in functioning bowel
• Avoids risk of second pull through.
29. Leveling colostomy –
Disadvantages
• No benefits of protective colostomy
• Length of colon mobilized and removed may
be longer
Operation technique
• Colostomy performed at the level of normally
innervated ganglion cells as ascertained on
frozen section i.e., just proximal to the
transition zone.
30. Leveling colostomy – operation technique
• Preoperative preparation
– Rectal washouts
– Broad-spectrum, intravenous antibiotics just prior to incision
– No formal bowel preperation is required or effective
• Incision
– Oblique incision in left lower quadrant
– If level of aganglionosis is not readily apparent, incision can be
extended transversely across the midline.
31. Leveling Colostomy
In general, a 1 × 0.5-cm biopsy specimen is
taken and interrupted silk or polyglactin
sutures are placed to close the biopsy site
32. Leveling colostomy -
Postoperative care
• The stoma usually begins to function within 24
hours, and feeding can begin shortly
thereafter.
• It is occasionally helpful to perform
intermittent dilatations of the proximal
ostomy to prevent narrowing of the opening
and allow the dilated proximal colon to return
to normal size.
33. Surgical procedures
• Rectosigmoidectomy (Swenson and Bill -1948)
• Retrorectal –transanal approach (Duhamel -1956)
• Endorectal procedure (Soave -1964).
• Laparoscopic assisted transanal endorectal pull-through
(LATEP) – Georgeson et al(1990’s)
• Transanal endorectal pull-through (TERPT) - De la Torre and
Ortega-Salgado and Langer et al in the late 1990s.
• The basic principle of all the procedures is to bring the
ganglionic bowel down to the anus
34. Schematic illustrations of several operative pull-through
techniques for the treatment of Hirschsprung disease.
35. Preoperative assessment during definitive surgery in staged
surgery
• History & physical examination
• Records of operative findings, procedures done, HPE reports
• X-ray abdomen – to identify any fecaloma
• Distal cologram- to outline the adequacy of the distal bowel for pull-
through without the need to mobilize the colostomy. (if initially right
Transverse colostomy )
36. Preoperative preparation for pull-through
• First generation cephalosporin or ampicillin + gentamycin or
amikacin + metronidazole started 24hrs prior to surgery
• Mechanical bowel preparation
• Twice daily rectal washes with NS starting at least a week or two
prior to surgery/ Distal colostomy washouts
• Low residue diet for 3days prior to surgery
• Gut irrrigation using polyethylene glycol solution (70ml/kg) on the
day prior to surgery
• On the morning of the surgery a rectal flatus tube is inserted to
ensure complete evacuation of colon.
37. SWENSON’S PULL HROUGH
Surgical principle is to remove the
diseased portion of the bowel that is a
aganglionic distal rectum &
anastomosing normal colon to lower
rectum to maintain the continuity to
allow normal defecation
Orvar Swenson, MD, 1909-2012
The first ever pull through procedure described for treating
HD & published by Swenson & Bill in 1948
38. Swenson’s Pull-through
• Initially anastomosis used to be
completed at the anorectum (2cm from
dentate line)
High incidence of enterocolitis (early
16%, late 27%).
• Modified by
– Resecting virtually whole of the
posterior rectal wall (very top aspect
of IAS)
– Making an oblique anastomosis
– leaving 1.5 to 2cm anteriorly,
– 1 to 1.5cm on both sides &
– 0.5 to 1cm posteriorly from dentate
line
39. Swenson’s Pull-through
• Position
– Should provide simultaneous
exposure of the perineum &
abdomen
– Lithotomy position
– Pelvis is allowed to drop back
over the lower end of the table &
legs are strapped over the
sandbags/ stirrups.
– Foley catheter is inserted into the
bladder
40. Swenson’s Pull-through
• Anal dilatation – slow & gentle anal dilatation
• Incision
– Oblique /Modified hockey stick incision in LLQ incorporating the
colostomy.
• Colostomy mobilised
• Denis Browne retractor applied
• Urinary bladder is lifted forward out of abdomen by stay sutures
• Sigmoid colon is mobilised by dividing sigmoid vessels & retaining
the marginal vessels
• It may be necessary to mobilise the splenic flexure to obtain
adequate length.
41. Swenson’s Pull-through
• Bowel is divided at the rectosigmoid
junction & removed
• Peritoneum is divided around its lateral &
anterior reflection from the rectum
exposing the muscle coat of rectum
• Dissection extends around the rectum,
keeping very close to the bowel wall.
– to prevent damage to the pelvic
splanchnic innervation.
42. Swenson’s Pull-through
• Dissection should commence from side to
side & in an anterior to a posterior
direction with the rectum being gradually
dissected out in a circumferential manner.
• Dissection is done extensively posteriorly
& on both sides but less anteriorly
44. Swenson’s Pull-through
• An incision is made anteriorly through the rectal wall about 2 cm
from the dentate line, extending halfway through the rectal
circumference (9 to 3o’clock)
• A clamp is inserted through this incision to grasp multiple sutures
placed through the cut end of the proximal colon
45. Swenson’s Pull-through
• The normal colon is pulled through the pelvis and out through the incision in
the everted rectum.
• An outer layer of interrupted 4-0 absorbable sutures is placed through the
cut muscular edge of the rectum and the muscular wall of the pull-through
colon.
46. First the anterior muscular anastomosis is completed.
Incision on the rectum is extended 1-1.5cm from dentate line on both sides
& 0.5 – 1cm posteriorly
Through the diagonal excision of the rectum, the internal sphincter is
preserved to maintain fecal continence & partial sphincterectomy is done
in posterior direction to reduce the risk of post-op HAEC
With traction on the three o'clock and six o'clock sutures, the left posterior
quadrant of the muscular anastomosis is done.
In a similar manner, the right posterior quadrant of the anastomosis is
completed
47. Swenson’s Pull-through
• When the outer layer (muscular) anastomosis is completed, the end of the
pulled-through colon is incised a few millimeters from the muscular suture
line.
• The mucosa of the cuff of the everted rectum is anastomosed to the mucosa
of the pulled-through colon ( interrupted 4-0 absorbable sutures).
• When anastomosis is completed, the sutures are cut, allowing the
anastomosis to retract within the anus.
48. Post op care
• keep the infant on total parenteral nutrition
for 7 days postoperatively and then gradually
start oral feeds.
• The urethral catheter is removed after 3 days.
• Antibiotics are discontinued after 5 days.
• Rectal examination is performed 2 weeks later
during an outpatient visit.
49. Experience with Swenson’s procedure
• Mortality
• The mortality after Swenson’s operation is reported to be 0–
5.8%
• Postoperative mortality is considerably increased in patients
in whom anastomotic leaks occur
• Significantly higher in babies with Down’s synd
• Bowel control
• Bowel control increases with age
• A followup of 5 years is required for complete evaluation
• Best predictors of abnormal bowel habits by sherman et al
are – temporary soiling after discharge and rectal stricture.
50. Experience with Swenson’s procedure
• constipation is the most common late
complication
• Soiling
• Temporary soiling after discharge was the only factor which
influenced the occurrence of soiling at follow-up
• Influence of Trisomy 21 on Bowel Control
• Studies show 10-15% of association
• More than 3/4th of patients with Down’s synd had
completely unsatisfactory outcome.
• Attainment of normal post op defecation is dependent on –
intensity of bowel training, social back ground, intelligence
of child and motivation to be socially clean which are lacking
in these children.
51. Persistent Bowel Symptoms due to Associated Intestinal Neuronal Dysplasia
– HD is associated with intestinal neuronal dysplasia (IND) in
about 25% of patients
– Patients have constipation, enterocolitis or soiling.
• Rectal stricture
– 9.5% after swenson’s procedure, 4.3% required operation, higher
incidence is seen in patients operated before 4 months of age.
• Fistulae were rare
• Other rare complications are – intestinal obstruction,
urinary incontinence, sexual dysfnction
• Enterocolitis remains the most serious complication.
53. Duhamel operation
• Bernard Duhamel first described his operation for Hirschsprung‘s
disease in 1956.
• The procedure consisted of a retrorectal dissection, whereby a
significant portion of the aganglionic rectum was preserved and
anastomosed to ganglionated proximal colon.
• The advantages of this procedure included
– Ease of performance,
– Reduction of anastomotic leaks and strictures,
– Retention of anal sensory receptors, and
– Preservation of the nervi erigentes.
54. Duhamel operation
• Operative principles
– Minimal pelvic dissection
– Retrorectal approach for the pulled-through colon to anal
opening
– Partial disruption of internal anal sphincter posteriorly
– Preservation of the anterior wall of the rectum & its nerve
supply
– Elimination of colo-rectal septum with wide side-to-side
anastomosis (stapled/crushed) between the anterior aganglionic
& pulled down ganglionic colon
55. Modifications
• In 1956 1st description - Anal transverse incision
was made at the ano-cutaneous junction- high
anal incontinence & prolapse
• In 1959 - Grob modification- post. anal wall
incision 2-2.5cm above anocutaneous junction- to
preserve IAS – high incidence constipation &
fecalomas
• In 1960,Duhamel-Pages modification - Anal
incision 1-1.5cm above pectinate- preserves 1/3rd
of IAS- less soiling & less constipation.
56.
57. Modifications
• Centered around the elimination of the
common wall of the rectal pouch spur
• 1964 Zachary & Lister - O shaped clamp
• 1966 Talbert - Suturing & stapling device
• 1987 Steichen - EEA
• Martin & Caudill – End-to-side anastomosis
58.
59. Duhamel procedure.
• Operation generally done when the child is 6-
12 months age & wt 10kg
• Prior to surgery rectal examination should be
done to ensure rectum is empty
• Child placed in lithotomy position with proper
padding
• Child cleaned, draped & catheterized
• Incision – muscle cutting hockey stick incision
is given
60. Duhamel procedure.
• Colostomy mobilised & dismanteled, transected
• Alternatively the colostomy site is removed with an automatic
stapling device.
• Proximal colon closed with a running silk suture
• 4 stages
– Mobilisation of upper colon & closure of the rectum
– Preparation of retrorectal space
– Endoanal incision
– Retrorectal pull-through procedure
61. Duhamel procedure -Mobilisation of colon
• Proximal mobilisation is done- it can be
brought easily to below the pubic symphysis
– May sometimes need division of left colic artery/IMA at
aortic root
– Marginal artery of Drumond should be preserved so that
colon viability is based on the left branch of middle colic
artery
62. Duhamel procedure – Closure of rectum
• Peritoneum over the mesosigmoid
is incised both laterally & medially,
joined anteriorly in the colo-vesical
pouch
• Both the ureters are identified
• Colon mobilised distally upto the
level of pelvic peritoneum
• The rectum is transected just above
the pelvic peritoneum (and closed).
63. Duhamel procedure-
preparation of retrorectal space
Opening of the mesorectum provides
access to the retrorectal space
The blunt dissection is carried out with
index finger/ long curverd forceps with a
small sponge/ long kelly’s clamp
The dissection is carried down to the pelvic
floor so that the assistant’s finger can be
felt when inserted no further than 1 –
1.5cm into the anus
64. Duhamel procedure-Endoanal incision
– A semicircular incision (posterior 1800 ) is made on the rectal
wall between silk stay sutures placed at 3, 6 & 9 O’ clock
positions
– The incision should be 0.5 – 1.0 cm proximal to the dentate line
• .
65. Retrorectal pull-through
• The kelly’s clamp/long curved
forceps with sponge is passed
from abdomen through the
retrorectal space
• The sponge is grasped with
another long curved forceps
through the incision
• Using sponge as a guide, forceps
is drawn in a retrograde direction
into the abdomen
66. Duhamel procedure.
• The proximal colon is grasped with the
forceps and drawn downward into the
retrorectal space to the level of
endoanal incision
• Care should be taken that bowel is not
twisted, not in tension, mesentry to be
directed posteriorly in sagittal plane.
67.
68. Duhamel procedure.
• Anastomosis technique
– Two long kocher clamps are inserted with one blade in the
rectum & other in the drawn colon
– The bases of the clamps are held apart so that Their end
points meet in an inverted V at the apex of the rectal
pouch
– The position of the clamps is checked by direct abdominal
palpation
69. Duhamel procedure.
• The walls of the colon & rectum deprived from circulation necrotize & the
clamps with necrotic tissue slides out of the anus (after 4 – 10 days)
• By this way a large enterotomy is carried out with a longitudinal
anastomosis between the drawn colon & native rectum
• Disadvantages –
– The protrusion of the handles of the clamps through the anus-
inconvenient to the child.
– Incomplete division of the colo-rectal septum
– Occurrence of stenosis
70. Alternative method
• The proximal end of the rectal stump
is kept open
• A longitudinal colotomy is made on
the pulled down colon opposite the
open rectal stump
• GIA linear cutter is inserted through
the anus with one blade in the
rectum & other in pulled down colon.
71. Alternative method
• Care to be taken that the entire length is
included and the tip of the stapler is
protruding well beyond the rectal stump &
colostomy in abdomen
• The stapler is then fired to complete the
longitudinal anastomosis & division of the
common wall.
• In case the entire common wall is not
divided, the same needs to be completed by
another firing with the stapler now applied
from the abdominal end in prograde
fashion.
72. Duhamel procedure.
• The open proximal end of the rectal stump is anastomosed to the
colostomy on the pulled down colon in end-to-side fashion…
Martin’s modification
• The anastomosis is extraperitonealized after placing a small pelvic
drain of CRD
• Peritoneum on both the medial & lateral aspects of pulled down
colon is repaired
• Abdominal wound closed in layers
• Rectal pack of paraffin gauze is applied, removed after 24hrs
73. Complications and results
• Anastomotic leak – 2.2%
• Necrosis – 0.09%
• Stricture – 0.7%
• Mortality rate – 1.6%
• Majority of post op deaths are related to
enterocolitis (incidence – 5-26%)
• Incontinence – 0-20%
• Constipation and fecal impaction due to larger
reservoir – 5-8%
• Lower UTI, ? Partial detrussor denervation
74. • Primary vs staged Duhamel’s
• Limited studies are available.
• Laparoscopic Duhamel’s procedure
– Laparoscopic techniques have mainly been described
for Swenson’s procedure and less frequently for
Duhamel’s.
– Bowel biopsies are taken laparoscopically to
determine the extent of aganglionosis before ablation.
– Further steps – laparoscopic mobilization, dissection
and closure of rectal stump and laparoscopically
controlled pull through.
75. Postulated advantages
– Visualization
– Atraumatic dissection
– Less post op pain
– Faster recovery
Duhamel’s procedure for re-do pull through is
Indicated in patients with
– Recurrent fecoloma formation
– Recurrent episodes of enterocolitis
– Retained aganglionosis
– Segmental bowel dysfunction with bowel dilatation
76. SOAVE’S (BOLEY SCOT)
ENDORECTAL PULL-THROUGH
The operation based on removing the mucosa and submucosa of
the rectum and pulling ganglionic intestine through the aganglionic
muscular cuff
By remaining within the muscular cuff of the aganglionic segment,
important sensory fibers and the integrity of the internal sphincter are
preserved.
Avoids injury to the pelvic nerves
77. Indications
• Hirschsprung’s disease
• Multiple Juvenile polyposis
• Ulcerative colitis
• Familial poliposis.
History
• 1955 Roumaldi proposed it at Roman society of surgery
• 1957 Soave used it for ARM with fistula & in 1961 he
performed this tech for HD.
• 1964 Boley modification- Primary anastomosis
78. • Coran & Weintraub modification – eversion of
submucosal-mucosal tube onto the perineum to
facilitate anastomosis
• Rintala & Lindahl- Transanal approach combined
with an open laparotomy for mobilization of
aganglionic segment
• Georgeson- Lap assisted mobilization of
aganglionic segment
• Torre-Mondragon & Ortega-Salgado– entire
dissection & mobilisation via transanal route
79. •In Original Soave procedure the pulled through colon is left hanging
beyond the anal verge.
•A•fter a period (~ 2 wks) to allow adherence of the bowel to the
anal tissues,the protruding segment was resected
•No anastomosis.
•Boley (1964)- performed a primary anastomosis at the anus.
Endorectal Pull-through
80. Endorectal Pull-through
Preparation
• Upto 1980’s - >5 months & weight > 8 kg
• If soave’s procedure is performed with in 3 months of life, chronic
inflammatory process of rectum (because of chronic proctitis leading to
tenaceous adhesions on submucosal layer) are generally avoided.
• Procedure does’t require any protective colostomy
• Aim- achieve radical treatment with out contaminating the operative field
• Colostomy is indicated if – acute enterocolitis/ intestinal obstruction
• Colostomy is done in the most distal part of the ganglionic colon
leveling colostomy.
• In order to achieve this it is necessary to perform multiple seromuscular
biopsies intra operatively.
81. • Preparation starts from one week before the
procedure to reduce complications
• Rectal probing should be repeated and
alternated with evacuating enemas.
• Perioperative IV antibiotic prophylaxis is
started 1 hour before surgery.
82. Soave’s – operative tech
• General anesthesia
• Catheter placement
• Performing wide dilatation of the anal canal
using two fore fingers – essential for sucessful
pull through procedure.
• Supine position with buttocks lying at the
extreme edges of operating table and legs
hanging freely wrapped in drapes and fixed to
prevent slipping of patient pelvis.
83. Laparotomy
• Paramedian left incision/ pfannensteil incision
• In patients with level ileostomy for total colonic
aganglionosis, a xiphopubic median incision is required in
order to perform an endorectal ileal pull-through
procedure.
• All mesocolic adhesions to the left parietal peritoneum are
dissected up to the splenic flexure (classic form of HSCR).
• Before starting endorectal dissection, it is essential to
perform multiple seromuscular biopsies of the rectum and
colon in order to evaluate the length of the aganglionic and
associated hypoganglionic segments
84. • Seperation of seromuscular from mucosal
layer of rectum
• Most technically difficult and peculiar step
• mepivacaina 2% with epinephrine 1:100,000
(10 μg) in 10 ml of normal saline solution is
injected between the layers in order to
facilitate initial seperation
85. Endorectal Pull-through
• The endorectal dissection is started
approximately 2 cm below the peritoneal
reflection
• The seromuscular layer incised with
either sharp dissection or cautery.
• Once the submucosal layer is reached the
seromuscular layer is divided
circumferentially using blunt dissection
with hemostat/Kitner dissector.
86. Endorectal Pull-through
• After the plane is established, dissection is continued distally.
– Once muscular cuff begins to develop, traction sutures placed in
muscle in each quadrant.
• Communicating vessels coagulated.
• Dissection is carried down within 0.5cm (in neonates) – 1cm( older
chidren) from dentate line
87. Endorectal Pull-through –Perineal dissection
• Narrow retractors placed at anal-mucocutaneous junction
• Kelly clamp is inserted into the rectum
• The mucosal-submucosal tube is then everted onto the
perineum.
88. Endorectal Pull-through –Perineal dissection
• The mucosal-submucosal tube is
incised on the anterior half
0.5cm – 1cm from the dentate
line
89. Endorectal Pull-through –Perineal dissection
A Kelly clamp is inserted into this
opening for grasping the two
previously placed traction sutures.
Great care is taken not to twist
90. Endorectal Pull-through –Perineal dissection
Anterior ½ of the ganglionic colon
is incised & anastomosed to the
anterior half of the mucosal-
submucosal tube with interrupted
absorbable sutures
One ¼ of the remaining
Final ¼
invert the neorectum into correct
position
91. Endorectal Pull-through
• The pulled through colon is attached with seromuscular bites
to the muscular cuff to prevent prolapse.
• No drain is placed
92. PRIMARY PULL THROUGH
IN NEONATES
All the surgical procedures described have been performed as
primary/single stage with good & comparable outcome
93. Primary Versus Staged Pull-through
• Principle
– Colonic dilatation can be quickly controlled by rectal washouts -
Calibre of the pull-through bowel is near normal-allows accurate
anastomosis-minimizes leakage & cuff infection
• Advantages of primary pull-through in neonates
– Specific stoma complications are avoided
– No. of admissions & hospital stay reduced
– Anal function and the anorectal reflex are reestablished as early
as possible.
• If attempted in older children hugely dilated colon segment (normal
ganglionic segment)needs to be resected
94. Selection criteria for Primary Pull-through
Parameter Primary Staged
Presentation Early Delayed presentation (very
dilated bowel)
Disease invovlement Rectosigmoid Long segment, TCA
Enterocolitis Absent/resolved Active/severe
Rectal washes Effective decompression No decompression
General condition Stable Deteriorating
Local expertise Frozen section histology Not available
95. LAPAROSCOPIC PULL-
THROUGH
Avoidance of a painful abdominal incision,
Rapid return of bowel function,
Shorter postoperative recovery,
Improved cosmetic appearance.
96. • In the early 1990s, Georgeson et al described a minimal access approach,
consisting of a
– Laparoscopic biopsy to identify the transition zone,
– Laparoscopic mobilization of the rectum below the peritoneal
reflection, and
– Short endorectal mucosal dissection from below.
– The anastomosis was done from below after prolapsing and excising
the rectum.
97. • Multiple reports documented a short time in the hospital, and early
results were equivalent to those reported for the open procedures.
• Subsequently, laparoscopic approaches have been described for the
Duhamel and Swenson operations, with excellent short-term results
reported
98. Laparoscopic Endorectal Technique
• With the patient positioned transversely at the end of the operating table, CO2
insufflation of the peritoneal cavity was performed using a Varess needle
inserted through the abdominal wall.
• Three 5mm (3mm) trocars were inserted as shown
• Additional midline suprapubic trochar site is useful to provide pelvic retraction &
hold the colon in traction during dissection of pelvis
99. Laparoscopic Endorectal Technique
• Dissection and leveling of the
aganglionic segment are performed as
in the open technique.
• Blood vessels may be ligated with
surgical clips or cautery for smaller
vessels .
• Once mobilization is complete, the
surgeon moves to the perineum, where
a trans anal dissection and anastomosis
are performed
101. Transanal Endorectal Pull-through
• Selection criterion
– Neonates, infants (proximal bowel not much
dilated)
– A barium enema study must suggest the diagnosis
of HD & also the level of aganglionsis
– Confirmed diagnosis of HD
– HD limited to rectosigmoid or short segment
102. Transanal Endorectal Pull-through
• Advantages of one-stage anal procedures
– Avoidance of multiple laparotomies with its associated complications
– Avoidance of colostomy with its associated complications
– Reduced operating time
– Less blood loss
– No pelvic structure damage
– Decreased need of analgesics
– No external scars & Improved cosmetic appearance
– Single hospital admission
– Short hospital stay
– Lower hospital costs
– High degree of parental acceptance
103. Transanal endorectal pull through -
procedure
Preparation
– diagnosis is confirmed by rectal biopsy
– Prior to surgery, the colon must be decompressed and
enterocolitis, if present, controlled
– Nutritional status must also be evaluated and optimized.
– In an older child with severe enterocolitis or massive colonic
distension, a defunctioning stoma should be considered
– routine preoperative mechanical bowel preparation is
unnecessary
– Mechanical
– irrigation of the bowel can be accomplished with equal
effectiveness from below once the child has undergone
anesthesia.
– Intravenous prophylactic broad spectrum antibiotics are used
104. Transanal endorectal pull through -
procedure
• General anesthesia
• Lithotomy position/ prone jackknife position
• Urinary catheterization is optional
105. Submucosal Dissection
• anal retractor or retraction sutures are placed
• submucosal injection of a dilute epinephrine
solution or air
• rectal mucosa is circumferentially incised using
cautery approximately 3–5 mm from the dentate
line
• fine sutures are placed in the proximal cut edge
of the mucosal cuff, and traction is applied while
the endorectal submucosal dissection is carried
proximally
106. Mobilization of the Rectum
• When the submucosal dissection has been
completed, the rectal muscle is divided
circumferentially
• Dissection then continues proximally, dividing all
vessels
• When the peritoneal reflection is reached, the
sigmoid is then mobilized in the same fashion and
the rectum and sigmoid are delivered through
the anus
107. • Anastomosis
• colonic dissection is completed when the
transition zone is reached
• colon is divided at least 2 cm above the most
distal normal biopsy to prevent the possibility of
a transition zone pull-through
• rectal muscular cuff is then split longitudinally
• standard Soave-Boley anastomosis is then
performed.
108.
109. Transanal Endorectal Pull-through
• Contraindications
– Redo pull-through
– Grossly dilated bowel in older chidren
– Without confirmed diagnosis of HD
– Long segment HD/TCA
– Any H/O bleeding disorders
110.
111. Postoperative care
• Oral feeding can be started as soon as child starts to pass stools if there is
no abdominal distension
• Examination of perineal region
– To look for erythema/cellulitis
• Early sign of an anastomotic leak (leak uncommon)
• In cases of ERPT Per rectal examination with cotton tip applicator to
ensure patency of rectal anastomosis befor discharge
• Instructing the parents to apply thick coat of barrier creams
• Educating the parents regarding enterocolitis.
– Preventive measures
• Follow up to late complications
112. • Stooling pattern change in the first 2 yrs after pull-through
– Frequency
• 5-10 bowel movements/day – immidiately after pull-
through
• 1 - 4 bowel movements/day – within 6-12 months
• Normal pattern
– Constipation
• Slowly improves
113. Complications.
• All post-operative complications which are recognised during the 1st
4weeks following the surgery
• Factors which influence
– Extent of aganglionsis
– General condition of the child
– Technical expertise & experience of the surgeon
– Age at the time of operation.
– Whether or not colostomy done
– The administration of prophylactic antibiotics
– Family care
• The late follow-up offers the best oppurtunity to critically evaluate
the efficiancy & results of any particular surgical procedure.
116. Enterocolitis (HAEC)
• Can be severe or life threatening
• Clinical features
– Fever,
– Abdominal distention,
– Diarrhea,
– Elevated white blood cell count, and
– Evidence of intestinal edema on abdominal radiograph
• Reported incidence varies in literature (2% - 40%)
(depending on the definition)
• HAEC score may be useful
117.
118. Enterocolitis (HACE)
• Majority of the episodes occur within 2yrs ofter pull-through
• There is no correlation between enterocolitis before & after surgery
• The incidence of enterocolitis directly correlates with mortality
– In a survey by AAP (1196 cases) , 14% developed enterocolitis with a
mortality of 30%
– Swenson’s series of 880 cases death after discharge from enterocolitis
– 1%
• Early recognition with prompt management influence the outcome
119. Enterocolitis
• Swenson & Fisher (1956) advocated rectal tube decompression for
initial management
• Other measures
– Aggressive fluid resusciation
– Bowel rest
– Broad spectrum antibiotics
– Resection with Diversion if peritonitis or clinical worsening
occurs
• Children with repeated bouts of enterocolitis needs to be evaluated
for mechanical obstruction
– Contrast enema, manometry, rectal biopsy
120. Enterocolitis
• Most patients will improve with time
• Patients with persistent enterocolitis despite investigation
– Can be managed temporarily with botulism toxin
– Permanently by internal sphincterotomy ( Polley et al & Marty
et al)/posterior myectomy
• Preventive measures to minimise the risk of HACE
– Chronic administration of metronidazole ( 1-2months) or
probiotic agents
– Prophylactic rectal irrigations(Marty et al)
– Should be advised particularly in those who are thought to be
at higher risk for this complication on the basis of clinical or
histologic grounds.
• It is extremely important that the surgeon educate the family
about the risk of this complication
121. Voiding & sexual dysfunction
• Many of the operations for Hirschsprung's disease have been designed
specifically to avoid pelvic nerve injury.
• Overall, the incidence of impotence and urinary dysfunction is quite low.
• Postoperative enuresis ~9.5%.
– Swenson 10.4%
– Duhamel 14.3%
– Soave 15.3%
• More recent series report no incidence of impotence or urinary problems.
122. Late mortality
• Most common cause is enterocolitis
• Other causes of death
– Intestinal obstruction
– Pneumonia
– Nonrelated medical disorders.
• In most studies the differentiation of early & late deaths is lacking
• No specific pull-through procedure is associated with higher rate of
late deaths
123. Overall quality of life
• Is difficult to assess
• Overall quality of life was described as quite good with ~94%
of children becoming well adjusted members of the society
• Developmental milestones are satisfactory in ~95% cases
• School performanace is satisfactory in ~ 82%
• Clearly children with poor functional outcome have
psychosocial problems
Composed of striated muscle, the external sphincter has three separate fiber bundles or loops: subcutaneous, superficial, and deep. It is useful to consider the three parts separately (Figs. 12.9 and 12.10 ), but the three loops together form an efficient anal closure. Any single one of the loops is capable of maintaining continence to solid stools, but not to fluid or gas. The subcutaneous portion surrounds the outlet of the anus, attaching to the perianal skin anteriorly. Some fibers completely encircle the anus.
Once the peritoneum is entered, an attempt should be made to define a gross transition zone. The bowel proximal to the transition zone is normally dilated and has a diffuse hypertrophy of the muscular layer with no clearly distinguishable tenea. In neonates, such a transition often may not be seen. If this is the case, a good starting point is just above the peritoneal reflection.
A pair of fine, sharp scissors is used to make an incision only through the seromuscular layers. The muscular layer, which is fairly thick, even in the aganglionic section, makes this dissection fairly easy. Each biopsy specimen is sent for frozen section, progressively moving more proximally until both ganglion cells, as well as a loss of hypertrophied nerve bundles, are seen. Hypertrophied nerve bundles, despite the presence of ganglia, indicate that one is still in the transition zone. Another biopsy specimen should be taken several centimeters more proximally. Importantly, the transition zone varies from the anti-mesenteric and mesenteric sides of the bowel. Thus, the surgeon must confirm this correct level by sending a frozen section on the mesenteric side of the colon as well.
Once the diagnosis of Hirschsprung’s disease (HD) has been confirmed by rectal biopsy examination, the infant should be prepared for laparotomy. Biopsies for frozen sections are taken to determine the level of transition and a colostomy is placed just proximal to the transition zone.
If the newborn has enterocolitis complicating HD, he will require correction of dehydration and electrolyte imbalance by infusion of appropriate fluids. Thomas et al. [1] have demonstrated a relationship to Clostridium difficile and its toxin in about 30% of patients with enterocolitis in HD and suggested treating these patients with vancomycin during acute episodes. It is essential to decompress the bowel as early as possible in these babies. Deflation of the intestine may be carried out initially by rectal irrigations and when the baby is clinically stable a colostomy could be performed. Traditionally, a definitive pull-through operation for HD has been performed when the infant is 6 to 12 months old
Primary Swenson’s Pull-Through Operation:
Many surgeons have reported good results with primary neonatal pull-through operation for HD. Once the diagnosis of HD is confirmed, the neonate is
started on total parenteral nutrition 2 to 3 days prior to operation. Rectal irrigations are carried out twice a day for 3 days before surgery. Intravenous gentamicin and metronidazole are started on the morning of operation.