1. Introduction

2. Incision and Access to the Abdominal Cavity

a. Biopsy

3. Bowel Inspection

a. Division of Mesenteric Vessels

b. Rectal Dissection (Part 1)

c. Biopsy Result

d. Extension of the Proximal Point of Bowel Transection

e. Rectal Dissection (Part 2)

f. Repair of a Colonic Perforation

g. Rectal Dissection (Part 3)

h. Perineal Dissection

i. Coloanal Anastomosis

4. Proctocolectomy

5. Closure

Hirschsprung's disease is a congenital disorder with a reported incidence of 1/5000 live births with a male preponderance of 3:1-4:1; when the entire colon is involved, the ratio approaches 1:1. It is the main genetic cause of functional intestinal obstruction. Most cases are diagnosed in the first few months of life given classical presentation and ease of testing with rectal suction biopsy. The disease is due to the absence of enteric ganglion cells in the distal colon that results in functional constipation. Resection of the affected segment and bringing the normal bowel close to the anus has been the mainstay of treatment. Due to advances in surgical treatment over the past decades, a significant reduction in morbidity and mortality has been observed, and the previously multistage procedure can now be completed in one stage without an increase in complication rates.


<h4>CHAPTER 1</h4>

<p>This is a four-year-old for Hirschsprung's. We will make an incision. A half inch thick incision here - to be able to see the colon - the sigmoid and the descending colon, and part of the transverse. So what we will do here is after the incision, once we identify a possible normal area, we will take a biopsy and send it for frozen section.</p>

<h4>CHAPTER 2</h4>

<p>O-S, please. Cutting. Cutting. So we're making an incision through the skin and the subcutaneous tissue. You can see the dermal layer separating. And we can see the fat- subcutaneous tissue - adipose tissue. Army-Navy ready. Oh, sorry. Knife. Kelly. Or a Mosquito. Dissecting the oblique muscles. Pickup please. In. Mosquito. Metz. So we're getting the peritoneum. A Pickup. So best - normally safer to put your finger in, and we dissect that we avoid hitting, sorry, the intestines. A Mosquito.</p>

<h4>CHAPTER 3</h4>

<p>So this is the sigmoid. It seems like there's some biopsy sites here. Try to get the biopsy there. Okay. Okay, so again this is the - at birth, I think this child had 2 biopsies. This one looks like the first biopsy, more distal. And this is the proximal biopsy. This one came out positive. This one came out negative. So we'll probably get another small bite here. And this one we can bring down.</p>

<p>Metz. So I check with the light to check the vasculature - the blood supply. Seems like a negative biopsy site - here.</p>

<h4>CHAPTER 4</h4>

<p>Okay. Thank you. So, what we're doing now is we're dissecting the mesocolon. We have a negative biopsy here, so most likely this is not any more normal colon. So this will be removed. So I'm already starting my dissection while waiting for the results of the frozen section. So its best to stay close to the colon to save the vessels - underlying vessels. Richard.</p>

<p>So the frozen section came out. So our biopsy site here is positive, so this is what we'll bring down there. So I'll just extend the dissection here.</p>

<p>More of your light towards this area.</p>

<p>So our objective is to go as low as we can. So that once we start dissecting on the anus side, we just have a short dissection to go. The key is just to stick close to the colon, rectum, to avoid injuring specific nerves, which are important here in the pelvic side. So we're close to the anus. Almost there! So what I'm doing now is I'm milking. I'm milking the feces so that we can get a clear dissection.</p>

<p>Suture. Suture, 3-0.</p>

<p>I'm just finger dissecting the area so that we could be right there. So now we're transferring to the anal side. We already have dissected almost close to the anus here.</p>

<p>So we're putting stay sutures to open up the anus to be able to do a transanal dissection. Other countries would have what they call a "Lone Star." But this is an alternative. So you normally go to the dentate line with the first suture, and a little further out here to the gluteus. So we're starting dissection here in the - in the anal area. So we already have dissected the - retracted the dentate line. So can you do this please? So I mark it with a cautery. Suture. So you put stay sutures all around so it will be easier for traction. Mosquito ready, Mosquito. 3-0. Suture. Just a little more here. So that we see the… Suture. Pickup. Suture. Then you get all the sutures together and you pull it for traction. So we've freed everything so we can now pull it back down.</p>

<p>Hold please.</p>

<h4>CHAPTER 5</h4>

<p>[No Dialogue]</p>

Watch this full-length, narrated surgical video of a proctocolectomy for Hirschprung's disease performed in the Philippines during a surgical mission with the World Surgical Foundation.

DOI
Publication Date	N/A
Article ID	278.7
Production ID	0278.7
Volume	N/A
Issue	278.7
https://doi.org/10.24296/jomi/278.7

Open Proctocolectomy for Hirschsprung's Disease

Procedure Outline

Table of Contents

1. Introduction

2. Incision and Access to the Abdominal Cavity

3. Bowel Inspection

4. Proctocolectomy

5. Closure