V3-10: LAPAROSCOPIC-ASSISTED MACE CREATION AND TAKEDOWN OF CECOSTOMY TUBE
VideoIntroductions and Objectives
The Malone antegrade continence enema (MACE) has become a common means of managing chronic constipation in children with neurogenic bowel. An alternative to this surgical approach is the Chait cecostomy tube, placed percutaneously by interventional radiologists. There are advantages to both, but recently, we have encountered patients who did not like the appearance and occasional leakage of the cecostomy tube, as well as the need for periodic changes and concerns over inadvertent removal, requesting conversion to a MACE.
A 15 year-old girl with sacral-level, ambulatory spina bifida presented to our clinic with such a request. Laparoscopically, the appendix and right colon are mobilized, and the cecostomy tract is identified. Once sufficiently mobilized so as the tip of the appendix can comfortably reach the umbilical port site, attention is turned to the exterior. The cecostomy tube is removed, and the tract mobilized into the peritoneal cavity. The defect is closed in two layers, and a stay stitch is placed at the base of the appendix. For stomal continence, a cecal wrap is performed over the appendix with several interrupted silk sutures, incorporating a small amount of appendiceal serosa. The sites are closed, the appendix is brought to the umbilicus and a previously made v-flap, and is secured with interrupted sutures.
Three months post-operatively, the patient is very happy and totally continent. She flushes the MACE every other day, and has no stomal leakage. Cosmetically, she is pleased as well, and able to wear normal underwear and swimsuits.
In patients desiring to be rid of their externalized cecostomy tube, a laparoscopic-assisted approach to takedown and conversion to a MACE is feasible, even in a previously operated abdomen. This may also be advantageous when transitioning these children to adult care, as we have not found many adult interventional radiologists interested in cecostomy tube care and exchanges.