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A. INTUSSUSCEPTION

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INDICATIONS
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Intussusception occurs most commonly in infants from the age of a few months to 2 years. Time must be taken to correct dehydration or debility by administering parenteral fluids. A stomach tube should be passed to deflate the stomach and to reduce the danger of aspirated vomitus to a minimum. If the intussusception has been of considerable duration and there is evidence of bleeding, as in the characteristic mahogany stools in infants, blood products should be administered with the operating room alerted and hydration established satisfactory for operation. The child is taken to the x-ray department, and here hydrostatic reduction by barium enema is attempted, utilizing a pressure of no more than 3 ft. As much as 1 hour may be spent in this procedure as long as manipulation of the abdomen is avoided and the exposure to fluoroscopy limited as much as possible. If the intussusception (figure 1) is going to reduce, it will progressively do so. If this method fails, surgery follows immediately. If a mass lesion or cancer is suspected in an elderly patient, then a re-section should be performed rather than a manipulation.

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ANESTHESIA
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Meperidine or morphine should be added in appropriate doses in older infants and children. Endotracheal intubation on the conscious infant is the safest anesthetic technique, followed by general anesthesia.

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POSITION
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The patient is placed in a dorsal recumbent position. Feet and hands are held flat to the operating table by straps or pinned wrappings.

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OPERATIVE PREPARATION
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The skin is prepared in the routine manner.

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INCISION AND EXPOSURE
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In most instances, a transverse incision made in the right lower quadrant provides adequate exposure. The lateral third of the anterior rectus fascia and the adjacent aponeurosis of the external oblique are incised transversely. The lateral edge of the rectus muscle may then be retracted medially and the internal oblique and transversalis muscles divided in the direction of their fibers. If more exposure is required, the incision in the anterior rectus fascia may be extended, and a portion or all of the right rectus muscle may be transected.

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DETAILS OF PROCEDURE
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The major portion of the reduction is done intra-abdominally by milking the mass back along the descending colon, transverse colon, and ascending colon. When reduction has proceeded thus far, the remainder can be delivered out of the abdominal cavity. The mass is pushed back along the descending colon by squeezing the colon distal to the intussusception (figure 2). If traction is applied, it should be extremely gentle to avoid rupturing the bowel. The discolored and edematous bowel at first may not appear to be viable, but the application of warm saline solution may improve its tone and appearance. Unless the intestine ...

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