Umbilicus: A Site for Stoma in Hirschsprung's Disease.

Abstract

A 13-day-old male baby with the symptoms suggestive of HD and barium enema showing the transition zone (TZ) at the recto-sigmoid was admitted with progressive abdominal distention not responding to rectal washes. The baby was planned for sigmoid colostomy and seromuscular biopsy. A transverse skin incision of 2cms was made through the umbilicus under general anesthesia. The skin, subcutaneous tissue, and fascia were incised, and the umbilical vessels and urachal remnant were individually ligated apart from the opening in the fascia. At this point, a urethral sound was passed per rectally to guide the sigmoid loop towards the umbilicus. Stay sutures were taken and the loop of sigmoid colon was taken out. Biopsies were taken from the recto-sigmoid junction and site proximal to TZ. The bowel wall was fixed separately to the peritoneum and fascia with interrupted 5-0 absorbable sutures. The bowel was opened and everted with suturing to the skin (Fig. 1). Management of Hirschsprung’s disease (HD) has evolved in last one decade from staged procedure to single stage trans-anal pull through. But in developing country like ours, the presentation is generally late (most of them brought with severely dilated colon or enterocolitis) and where there is lack of facility for frozen section biopsy, staged procedures are still the standard of care. In this era of minimal access surgery, where a lot of stress is laid on cosmesis, role of umbilical incision for fashioning of colostomy and taking biopsies is a good alternative. Though trans-umbilical colostomies have been occasionally done in past for HD and anorectal malformations1,2,3, they are still not widely used.