HEGAZY SURGERY

1. Constipation & Incontinence
in Children
Mohamed El-Debeiky
MSc, MD, MRCSEd

2. Causes
• HSD
• ARM
• Idiopathic constipation

3. Hirschsprung’s Disease
• It is a form of chronic intestinal
obstruction caused by congenital
absence of ganglion cells in both the
intermuscular and submucosal
plexuses.

4. Pathologic Anatomy
• Distal Narrow
Segment:
Aganglionic
• Proximal Dilated
Segment:
Ganglionic.
• Transitional Zone:
Hypoganglionic.

5. Extent of Aganglionosis
• Short segment (75%):
Rectosigmoid.
• Long segment (20%):
Descending colon.
• Total Colonic (5%):
Colon and parts of
small intestine.

6. Clinical Picture
• Age: 50% neonates,
45% up to 2 yrs,
5% > 2yrs.
• Failure to pass
meconium within
48hrs
• Abdominal
distension.
• Constipation.

7. Clinical Picture
• Vomiting.
• Diarrhea (enterocolitis).
• Perforation.
• Rectal exmaination.

8. Differential Diagnosis
• Meconium plug, Meconium ileus,
Stenotic anus.
• NEC, Sepsis, Hypothyroidism.
• Functional constipation.
• Neuronal intestinal dysplasia (NID).

9. Diagnosis
• Plain X-ray
Abdomen.
• Barium Enema
(unprepared).
• Ano-rectal
manometry.
• Rectal Biopsy.

10. Surgical Treatment For
Hirschsprung’s Disease
• Three Stages: Outdated.
• Two Stages: Standard (colostomy, pull through).
• One Stage: Selected cases.

11. Age for definitive Pull through
• 9 months: Out dated.
• 6 months: Standard.
• Neonates: Selected cases.

12. Type of Surgery
• Abdomino-perineal pull through.
• Trans anal pull through.

13. ANORECTAL
MALFORMATIONS
- 1 : 4 – 5000 newborns
- Males > Females

14. TYPES OF DEFECTS ( classification )
MALE DEFECTS
1. Low Defects : Perineal fistula
Median raphe fistula
Bucket handle malformation
Anal stenosis
Anal membrane
2. Rectourethral bulbar fistula
3. Rectourethral prostatic fistula
4. Rectovesical ( bladder neck ) fistula
5. Imperforate anus without fistula
6. Rectal atresia and stenosis

15. Median raphe fistula

16. Rectourethral fistula

17. FEMALE DEFECTS
1. Low defect : Perineal fistula
2. Vestibular fistula
3. Vaginal fistula
4. Imperforate anus without fistula
5. Rectal atresia and stenosis
6. Persistent cloaca

18. Vestibular fistula
3 orifices

19. ASSOCIATED DEFECTS
Urogenital
- Most common
- 20 – 45 %
- The higher the malformation the higher the incidence
Sacrum and Spine
- Sacrum frequently abnormal deformed
reduced in number
hemisacrum
- Spine frequently shows hemivertebrae

20. D.D: Functional (Constitutional)
Constipation.
• Common complaint: Constipation or
incontinence.
• History: Period of normal defecation
followed by constipation.
• Age: from infancy to puberty.
• Causes: Emotional & stress, chronic
dehydration, anal fissure, drugs (opiates &
anticholinergic), hypothyroidism.

21. D.D:Functional Constipation
Diagnosis
• History: Personal,
Family.
• Examination:
Abdomen,PR
• Plain x-ray
• Barium Enema
• Rectal Biopsy ?

22. Contrast Eenema

23. D.D:Functional Constipation
Treatment
• Initial evacuation of retained stools by
enemas.
• Regular evacuation of rectum by
suppositaries.
• Stool softners.
• Treatment of anal fissurs.
• Dietary.
• Toilet training.

24. Stimulant laxatives
• Senna
• Biascodyl
• Glycerine
• MoM

25. Surgery

26. CONCLUSION
• Early detection, proper diagnosis &
management of constipation in
children gives excellent results.
• Hirschsprung’s disease should be
suspected in cases of constipation
resisting ordinary treatment.