Transanal Soave stage I extraction

Transanal Soave I stage extraction surgery for the treatment of congenital megacolon. 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. Treatment of diseases: congenital megacolon Indication The transanal SoaveI stage is suitable for: 1. Common segment of congenital megacolon. 2. Small age group, preferably less than 2 years old. 3. No multiple abnormalities found in the abdominal cavity. 4. The preoperative expansion of the intestine segment recovered significantly after washing the intestines, and it was not difficult to get through the anus. 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. Expand the anus and sew 4 traction lines in the full layer of the anus to make the anus open. 2. Make 2 traction lines above the dentate line to lift the rectal mucosa above the dentate line. 3. Circularly cut the rectal mucosa at a distance of 0.5 cm from the dentate line. 4. Separate the rectal mucosa along the submucosal layer, and use an electric knife to stop bleeding while separating. The separation is 6-7 cm long. At this time, the free mucosa has exceeded the pelvic peritoneum, and the intestine is relatively free. The incision of the rectal muscle layer, and the abdominal cavity through, circular cut muscle layer, free upper rectum and sigmoid colon, can be easily pulled out of the anus. 5. Ligation and severing of the mesentery, dragging the dilated sigmoid colon, and taking part of the intestinal wall biopsy to determine the resected end of the resection. At this time, the rectal muscle sheath is cut longitudinally from the posterior wall, and the excess muscle sheath is cut in a curved shape to retain The muscle sheath is high in front and low in the front, and the front is kept 3 cm from the dentate line and 0.5 cm behind. 6. The remaining proximal intestinal pulp muscle layer and the rectal muscle sheath were sutured intermittently for one week, and the whole intestinal layer was dragged and sutured intermittently with the rectal mucosa above the dentate line for one week. 7. Place one anal canal in the rectum. complication Dragging out the mesenteric hemorrhage Close observation of changes in the condition after surgery, such as the occurrence of mesangial vascular ligation line loosening may cause massive intra-abdominal hemorrhage, if necessary, open laparotomy and laparoscopic hemostasis. 2. Pull out the bowel retraction During the operation, the intestine is freed from the intestine, preventing excessive tension and poor blood supply to the distal intestine. If the above complications occur, pelvic drainage and colostomy should be performed in time. 3. Anastomotic stenosis and constipation symptoms recurrence The anastomosis is a ring, so the anus must be adhered to after surgery. If the rectal muscle sheath is excessively retained, it may lead to constipation. Sometimes the resection of the diseased intestine can not cause recurrence symptoms. Therefore, the specimen should be taken at the end of the cut off the intestine to make frozen sections and observe the condition of the ganglion cells.