Total colectomy, rectal intrathecal ileal extraction

Total colectomy, rectal sheath ileal extraction for the surgical treatment of the whole colon-type ganglion-free megacolon. Congenital megacolon is a common digestive tract malformation (Fig. 12.13.1.5.1-0-1). It is due to the lack of ganglion cells in a certain intestine at the distal end of the colon, resulting in intestinal fistula and normal peristalsis disappearing. , the formation of functional intestinal obstruction, obstruction of the proximal intestinal dilatation, hypertrophy. 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 Total colon resection, rectal sheath ileum extraction is suitable for the whole colon type ganglion-free megacolon. 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 is usually performed with a left lower abdominal rectus abdominis incision or a left lower abdomen oblique incision. 2. First open the peritoneum of the ascending colon, then cut the peritoneum of the descending colon, and then cut the mesentery from the ascending colon, transverse colon and descending colon in order, and ligature the mesenteric vessels. 3. Free the whole colon, cut the rectal muscle layer at the reflex of the peritoneum, bluntly separate the rectal mucosa, and peel the rectal mucosa to the vicinity of the dentate line. 4. The surgeon transferred to the perineum, first anal expansion, circular incision of the rectal mucosa 1cm above the dentate line, and through the pelvic surgery field, the rectal mucosa along with the entire colon from the rectal muscle sheath, at the end of the ileum Cut off and suture the mucosa on the rectal dentate line in two layers, remove all the colon, and pull out the ileum and the rectal muscle sheath to place 2 rubber sheets for drainage. The surgeon changed the surgical gown and gloves, transferred to the abdominal surgery field, and fixed the top of the rectal muscle sheath with the ileum for a week. complication Total colon resection and ileal sheathing may last for a long period of time, and prolonged early care may result in perianal skin erosion.