Ostomy

"Doctor, you need to see this baby." Samedi calls me to the ER. "She's only 7 days old, but she's never had a bowel movement."

I pull back the curtain and see the frightened mother holding her newborn baby in her arms. The infant's belly is markedly distended, but still somewhat soft. I listen and hear good bowel sounds. The mother says she breastfeeds well and goes on to prove it by feeding the baby right in front of me. I examine the perineum and the anus is present.

"Samedi, get me a glove and some lubricant."

He comes back in a few minutes, I slip the glove on my right hand, apply some goo and gently press my pinky into the tiny anus slowly dilating it until my finger can go all the way in. It's a blind rectal pouch as I suspected.

I inform the parents that their little girl will need surgery immediately and they agree.

Without x-ray, I'm forced to guess exactly the extent of the malformation of the colon. I'm hoping it's just the sigmoid (the last part of the large intestine). Sarah and Simeon tag team the anesthesia calculating the tiny doses of Atropine and Ketamine for it's small, 2.4 kg frame. We strap her into the "papoose" so she can't move, prep her distended abdomen with betadine, scrub and drape and before cutting, pray.

I decide to gamble that I can make a colostomy from the descending colon so I cut a small circle out of her skin to the left of her bellybutton, cut through the fascia and muscles and enter the peritoneal cavity. Small intestines burst out under pressure and I can't get them back in. I move to the center and make a midline incision releasing the pile of intestines to the outside air. I then bring back those that have gone out the side hole and explore inside. The colon hasn't formed (atresia) all the way from beginning to end. The whole thing looks like a long appendix running from cecum to rectum.

Everything is so tiny. I take a part of the ileum about 10 cm from where it joins the cecum and clamp the bowel with non-crushing clamps. I divide the intestine and slowly identify the miniscule vessels in the mesentary and clamp/cut/tie them. I then open up the distal end and suction out all the meconium resting there and suture it closed in two layers. I then pull out the proximal part through the side window, sew the wall to the strong fascia, evert the gooey mucosa and suture that to the skin. I then suck out all the stool from 9 months in mommy and 7 days in the real world and close up the midline incision after irrigating profusely.

I write post-op antibiotic and immediate breastfeeding orders and go home.

Except for a fever the next day found to be malaria and treated with blind rectal pouch quinine suppositories, she has a routine post-op course and is just waiting to have her sutures removed in a few days.