You are on page 1of 25

Dr.Vivek Gharpure, M.Ch.

Consultant Pediatric Surgeon
Children’s Surgical Hospital
Government Medical College
MCRI Hospital
MIT Hospital
Kamalnayan Bajaj Hospital
Aurangabad, INDIA
Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Spectrum
• about 9-12 new cases diagnosed
every year
• Some referred with colostomy
• Since 1994, 87 patients have
undergone surgery for congenital
megacolon
• Boys:girls 79:8
Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Barium enema
Narrow rectum

Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Barium enema
Narrow rectum

Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Before colostomy

Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Endorectal pullthrough
• One stage pullthrough in 6 patients.
• Age 1month to 3 months
• Weight 3.5 kg - 4.5 kg
• Classical hirschsprungs’ disease
• Preliminary decompression by saline
enema for at least one week
• Indwelling flatus tube for two/three
days prior to surgery
Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Endorectal pullthrough
Steps
1. Scott-boley endorectal pullthrough
2. Classical soave in five patients
3. One had significant dilatation of
bowel despite colostomy
4. Other was the ‘first’ one stage
pullthrough
5. Three in older patients > 5 years or
repullthrough
Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Endorectal pullthrough
Preparation
1. Oral mannitol 6 ml/kg 4 hours prior to
surgery and then NBM
2. Low residue diet not necessary
3. Distal bowel washout once on
admission with saline
4. Patient admitted the afternoon prior to
surgery
5. One unit blood kept ready
Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Endorectal pullthrough
Steps
1. Long left paramedian incision
2. Transverse incision/oblique incision
not preferred. Does not allow easy
mobilization of splenic flexure,
Requires forceful retraction and more
assistants.

Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Endorectal pullthrough
Steps
1. Stoma taken down
2. Mobilize the left colon
3. High ligation of the inferior
mesenteric vessels
4. Preserve superior rectal if
possible
5. Ensure adequate length
Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Endorectal pullthrough
Steps
1. Mobilize the rectum
2. Peritoneum incised 2-3 cm above the
peritoneal reflection
3. Saline infiltration of the muscular coat
4. Separation of the mucosal tube
5. Dissection of the tube upto anal verge
from abdominal side. NO anal
dissection
Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Endorectal pullthrough

Steps
1. Bleeding in the cuff has rarely
been a problem. Except in older
patients. One or two vessels need
to be cauterized. ENT foreigh
body forceps very useful.

Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Endorectal pullthrough

Steps
1. Confirm extent bimanually
2. Invert tube
3. Divide anterior half
4. Pullthrough
5. Four quadrant anastomosis

Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Endorectal pullthrough
Steps
1. Check anastomosis
2. Pull bowel up
3. Excise excess cuff
4. Fix tube to cuff
5. Obliterate lateral gutter
6. Excise stoma
7. Close abdomen
Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Endorectal pullthrough
Steps
1. IV fluids, blood if required
2. Antibiotics, ceftriaxone and
gentamicin; or ceftriaxone alone.
3. Metrogyl NOT used
4. Bladder catheter for two days
5. Ryle’s tube till flatus passed
Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Endorectal pullthrough
IV fluids
1. 100 ml/kg isolyte p + 20 ml/kg
ringer’s lactate + 20-40 ml/kg
isolyte p in first 24 hours and next
24 hours
2. Kesol 1ml/100ml of iv fluids from
day one (surgery - day 0)
3. This is on the higher side but
works well.
Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Endorectal pullthrough
Steps
1. Usually oral feeds commence
within 48 hours and patient is off
IV by day 3.
2. Lactulose from the time patient
starts feeding and continued till 3
weeks
Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Endorectal pullthrough
Patient called on day 21 for digital
examination and anal dilatation
Dilatation taught to mother by me and
mother made to dilate.
Dilatation for at least one year
Monthly followup for 3 months
Then yearly followup

Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Endorectal pullthrough

N= 87
79 boys
8 girls

Age at operation 1 month to 4 years
Longest follow-up 11 years
Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Endorectal pullthrough
Complications N=87
Wound infection(excluding 2
colostomy wound)
Wound dehiscence 3

Residual aganglionic segment 2

Enterocolitis 3

Stricture 2
Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Hirschsprung’s disease
Complications N=87

Adhesive obstruction 1

Immediate revision procedures Nil

Repullthroughs Nil
Myectomy two

Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Hirschsprung’s disease
Complications N=87

Perianal excoriation All(temp)

Stomal excoriation NIL

Operative mortality 1

Death due to unrelated illness 2
Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Thanks to
1.Dean, Government Medical College
and Hospital, Aurangabad.
2.Dean, MGM, Medical College and
Hospital, Aurangabad.
3.Director, Children’s Surgical
Hospital.Aurangabad.

Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer
Create PDF with GO2PDF for free, if you wish to remove this line, click here to buy Virtual PDF Printer