Dr.Vivek Gharpure, M.Ch.

Consultant Pediatric Surgeon

Children’s Surgical Hospital
Government Medical College
MCRI Hospital
MIT Hospital
Kamalnayan Bajaj Hospital
Aurangabad, INDIA
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 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
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 Barium enema
Narrow rectum

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 Barium enema
Narrow rectum

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 Before colostomy

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 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
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 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
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 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
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 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.

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 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
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 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
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 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.

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 Endorectal pullthrough

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

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 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
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 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
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 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.
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 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
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 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

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 Endorectal pullthrough

N= 87
79 boys
8 girls

Age at operation 1 month to 4 years

Longest follow-up 11 years
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 Endorectal pullthrough
Complications N=87
Wound infection(excluding 2
colostomy wound)
Wound dehiscence 3

Residual aganglionic segment 2

Enterocolitis 3

Stricture 2
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 Hirschsprung’s disease
Complications N=87

Adhesive obstruction 1

Immediate revision procedures Nil

Repullthroughs Nil
Myectomy two

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 Hirschsprung’s disease
Complications N=87

Perianal excoriation All(temp)

Stomal excoriation NIL

Operative mortality 1

Death due to unrelated illness 2

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 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.

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