Duhamel surgery

Duhamel surgery is used for the surgical treatment of Hirschsprung's disease. Congenital megacolon is a common malformation of the digestive tract. It is caused by the lack of ganglion cells in the distal segment of the colon, resulting in intestinal fistula, normal peristalsis of the intestine segment disappearing, forming functional intestinal obstruction, obstructing proximal intestinal dilatation. Fat. The length of the intestines varies from a few centimeters, sometimes to the entire colon, and even to the small intestine. The latter has serious clinical symptoms and is complicated to treat. The most common type is the sigmoid colon below the sacral segment, and the proximal intestine near the sacral segment gradually expands until the dilated segment is called the transition segment. There is also a lack of ganglion cells in this segment of the intestine. In the dilated segment of the intestine muscle layer hypertrophy, chronic inflammation of the mucosa, and even ulceration, degeneration and spasm of the intermuscular plexus and submucosal ganglion cells. The length of the dilatation segment is also inconsistent with the age of the visit, and then gradually transitions to the normal intestine. The main point of congenital megacolon surgery is to remove the sacral segment, the transitional segment and some of the dilated bowel segments that cannot restore normal function according to the characteristics of the above pathological changes. Rectal anterior colectomy is an improved procedure based on the prolapse of rectal sigmoid resection. It is characterized by a wide dissection of the rectum, reduced anatomy of the pelvis, reduced surgical trauma, and reduced pelvic nerve injury. Opportunity. However, there are some shortcomings in this procedure. For example, the gap between the rectum and the colon is too small, the gate is easy to form, and the feces are stored in the rectum after surgery, so it is continuously improved. At present, only a few scholars still use the original surgery. Treatment of diseases: congenital megacolon Indication Duhamel surgery is suitable for: children with congenital megacolon more than 3 months (some authors advocate surgery in the neonatal period), after colostomy or strict bowel and bowel preparation, the general condition is better, no enteritis. Contraindications Severe malnutrition or combined with enterocolitis cannot tolerate surgery. The above-mentioned sick children should undergo colostomy first, and then the radical surgery should be performed after the general condition is improved. Congenital megacolon combined with other systemic severe malformations such as severe congenital heart disease, esophageal atresia, etc. should be performed first in the intestinal stoma, to be corrected for severely life-threatening deformities, and then megacolon radical surgery. Preoperative preparation In children with congenital megacolon, there is clinical colonic obstruction, abdominal distension, large amount of feces in the colon, absorption of toxins, malnutrition, impaired heart, liver and kidney function, and poor resistance. Therefore, system preparation should be performed before surgery. Surgery creates good conditions. 1. Preoperative barium enema, rectal manometry, rectal mucosal biopsy, cholinesterase determination, clear diagnosis and understanding of the extent of the lesion. 2. Preoperative blood and urine routine examination, liver and kidney function and electrocardiogram examination. 3. Prepare the bowel before surgery for colonic lavage with normal saline 3 weeks before surgery to remove the feces in the colon, relieve abdominal distension, restore intestinal tract, reduce symptoms of poisoning, improve nutritional status, and treat enteritis. The condition of the sick child is gradually improved, and the enema effectively relieves the functional colonic obstruction, so that the partially dilated bowel gradually returns to normal, which facilitates the scope of the resection in the operation. In colonic lavage should pay attention to: 1 must use isotonic saline, because low permeability liquid is easy to cause water poisoning, high permeability liquid is easy to cause salt poisoning. The most important thing is to accurately measure the amount of enema in and out, to prevent the instilled saline from staying in the intestine. The total amount of enema per time must not exceed 100ml/kg body weight. 2 enema should choose soft, but slightly thicker anal canal, easy to excrete feces from the anal canal. The enema should understand the extent and direction of the diseased bowel, and the tube should be gentle. Each time the enema is administered, the anal canal is passed through the sacral section to reach the dilatation section. Do not inject too much liquid each time, pour a certain amount of salt water, gently massage the abdomen, and squeeze the expansion section downwards, so that the gas, feces and liquid in the intestinal tract are discharged from the anal canal. After the daily enema, the purpose of cleaning the expansion section should be achieved. 3 In the winter enema, you should keep warm to prevent cold and respiratory infections. 4 For children with short sputum, you can pour "123 liquid" (ie 33% magnesium sulfate 30ml, glycerol 60ml, normal saline 90ml) before washing with normal saline. Infants can be half-infused, stimulate bowel movements, and then cleanse the intestines with saline. 4. If there is water and electrolyte disturbance, it should be corrected in time. Anemia can be transfused in small amounts. 5. Give low slag, easy to digest, high protein, high vitamin food during enema, give high nutrition in the intestine if necessary, actively improve malnutrition, and improve the body resistance of sick children. 6. Give intestinal sterilizing agent 3 days before surgery to reduce bacteria in the intestine and reduce the infection rate after surgery. 7. Preoperative blood. 8. Place the stomach tube before surgery, and place the catheter after disinfection in the operation area. Surgical procedure 1. Incision: Inferior rectus abdominis incision (or lateral median incision) in the left lower abdomen, the upper edge of the incision reaches 3 cm above the umbilicus, and the lower end reaches the upper edge of the pubis. 2. Open the anterior sheath of the rectus abdominis, separate the rectus abdominis, and incise the posterior sheath and peritoneum. The sigmoid colon is revealed and the hypertrophy and thickening of the sigmoid colon is revealed. The extent of the diseased intestine is carefully examined to determine the boundary of the intestine. The pelvic peritoneum was cut along both sides of the rectal bladder depression. 3. Expose the ureters on both sides, pay attention to protection to prevent injury. Free sigmoid colon and descending colon, cut off mesenteric vessels, and the proximal end is properly ligated. When treating a preserved mesenteric vessel, the marginal vascular arch should be preserved to ensure blood transport from the bowel. In order to make the descending colon with sufficient freeness so that there is no tension when the perineum is pulled out, it is generally necessary to cut the left colon artery and the sigmoid artery at the root. 4. The rectosigmoid resection was performed with a vascular clamp clamped above the peritoneal reflexion 2 cm above the dilated sigmoid colon and excised between the two clamps. The rectal stump was sutured with two layers of silk. The broken end of the proximal colon is also sutured with a silk thread and temporarily closed. 5. Free descending colon and colon left curvature: The common segment of the megacolon generally dissociates the left collateral of the colon, so as to ensure that the descending colon that is pulled out is dragged to the perineum without tension. If the colon is mostly involved, after the colon is cut off, the length of the proximal colon is not enough to be dragged outside the anus. The middle colon artery can be ligated and the right colon artery can be preserved, but the edge of the colon should be retained to pull out. There is enough blood in the intestines. If the left colon and transverse colon are involved, the sigmoid colon, descending colon and the left half of the transverse colon should be considered. At this time, the peritoneum of the ascending colon should be opened, and the ascending colon should be freed and rotated 180° counterclockwise, from the right side to the rectum. Towing out of the anus, the right colon artery should be preserved at this time. It is not possible to directly lower the ascending colon to prevent postoperative intestinal obstruction caused by kinking of the ileocecal and mesenteric vessels. If the mesenteric vasculature is found to be compressed in the ileum after colonic rectal anastomosis, the ileum should be severed, the mesenteric vessels should be returned to the dorsal side, the compression should be eliminated, and the ileal end-to-end anastomosis should be performed. 6. Use a finger or gauze ball to separate the connective tissue before the sac in the direction of the pelvic cavity. This step should be performed between the anterior tibial fascia and the rectal intrinsic fascia until the level of the dentate line. When separating, it should be close to the rectum, and the movement is gentle to prevent rupture of the anterior iliac vein. 7. The surgeon turns to the perineum to operate, first expand the anus, after the sphincter relaxes, clean the rectal cavity with 1:5000 New Cleaner gauze, then suture 4 traction lines at the anal margin to keep the anus open (or retract with anus) The device retracts the anus). The assistant placed the metal dilator to support the posterior wall of the rectum through the abdominal anterior intercondyal space. Before the operation, the posterior wall of the rectum was cut at 0.5~1cm proximal to the dentate line to achieve the penetration of the anterior anterior space. Sphincter. Using a long curved toothless sponge forceps, the incision enters the abdominal cavity through the anterior tibiofibular space, and the suture of the colon stump is temporarily clamped. The assistant positions the colon, and the mesangium is pushed backwards and slowly pushed into the pelvic cavity. Be careful not to twist the colon. The surgeon slowly dragged the colon out of the anus. Zhang Jinzhe designed the special sleeve to fix the dragged colon on the sleeve, cut the posterior wall of the rectum under the support of the sleeve, and the colon was pulled out with the sleeve, thus reducing the chance of contamination. 8. Suture the posterior wall of the colon and the subcutaneous tissue of the posterior margin of the anal canal. The posterior wall of the colon was cut at a distance of 0.5 cm from the distal end of the suture of the sarcoplasmic layer, and then the posterior wall of the colon and the skin of the anal canal were completely sutured. Excision of the excess anterior wall of the colon. Align the anterior wall of the anal canal with the posterior wall of the colon, and use two Kocher forceps to pour the "V"-shaped clamp. One arm of the forceps is placed in the rectal cavity, and the other arm is placed in the colon. The length is 3 to 4 cm long. Cross the top of the pliers and secure the two pliers. After a few days, the intestinal wall of the clamp was necrotic, and the proximal intestinal wall adhesions healed to form a new rectum ampulla. The anterior rectal wall has no ganglion cells, and the posterior wall is a colon with normal peristalsis. 9. When the surgeon is operating in the perineum, the assistant can fix the pelvic peritoneum by fixing the rectal blind end to the anterior wall of the colon with a few needles. Close the mesenteric orifice to prevent internal hemorrhoids. Wash the abdominal cavity with saline and then close the abdomen layer by layer. complication 1. Pelvic infection: This spread of infection can lead to diffuse peritonitis, which can cause sepsis and endanger the lives of sick children. There are many reasons for pelvic infection: 1 Insufficient intestinal preparation, there is still more feces in the intestinal tract during surgery (or large fecal stones in the expansion section before surgery, which cannot be removed by enema), resulting in contamination when the intestine is cut. Abdominal cavity and pelvic cavity. 2 free anterior intercondyal vaginal manipulation, tearing the rectum and polluting the pelvis. 3 The rectal blind end suture is not tight, or the clamp is too close to the blind end of the rectum to cause blind end perforation. 4 dragging out of the intestine, poor blood supply, or excessive tension, resulting in anastomotic rupture. Pelvic infection caused by rupture of anastomosis is one of the most serious complications of this procedure. In this case, proximal colostomy should be performed promptly to strengthen anti-infective measures and supportive therapy. If a pre-ankle abscess is formed, the tail bone can be removed for incision and drainage. If the chronic sinus is formed after draining the abscess, the fistula can be re-selected after the preparation. If the necrotic retraction exceeds 2cm, it should be pulled out again through the abdominal perineum. When the rectal blind end is perforated with fecal overflow to the abdominal cavity, the colostomy should be performed quickly, and the colostomy should be closed 2 to 3 months after the fistula heals. 2. Rectal blind bag: the most common complication of this procedure. The blind bag allows the stool to be stored, forming a fecal stone, and gradually expanding, compressing the bladder to affect urination, pressing the colon backwards, causing poor bowel movements. The fecal stone in the blind bag stimulates the sick child, often has a feeling of defecation, and may even accumulate and hemorrhage due to infection in the blind bag. For a long time, abdominal distension and difficulty in defecation are repeated, which is similar to the recurrence of the megacolon. At this time, the fecal stone can be touched during the anus examination. It should be cleared in time. The small blind bag can be removed with a ring clamp clamp. After the large blind bag is used to remove the fecal stone, the anus is extended and the intestine is kept, waiting for it to gradually shrink and then clamped and removed. 3. The interval between the rectal colons is too large, affecting defecation, causing the feces to be stored in the colon. When the symptoms are light, the anal sphincter can be adhered to. If the gate is too low, it should be removed with a ring clamp. 4. Fecal incontinence: When the lower end of the free rectum is pulled out, it should be close to the intestinal wall to prevent damage to the external anal sphincter. After the clamp removes more of the anal internal sphincter, it can form anal insufficiency and dirty feces. A few of them are difficult to cause bowel movement caused by low gate, and there are too many secondary stools. The treatment is the same as above. If the anal incontinence has not healed for a long time, the second stage can be an anal sphincter replacement surgery.