V548: Single Incision Laparoscopic-assisted Malone Antegrade Continence Enema Procedure Using Standard Laparoscopic Equipment
VideoIntroduction and Objectives
Laparoscopic-assisted Malone antegrade continence enema (MACE) procedure was first described with the use of three small skin incisions for placement of the camera and the working instruments. Compared with open surgery, this minimally invasive technique results in a more rapid recovery, decreased pain, and improved cosmesis. We describe a laparoscopic-assisted MACE procedure using a single skin incision at the umbilical site of the cutaneous appendicostomy.
A transverse incision is made in the umbilicus through its base to create dual “V” flaps. The peritoneum is entered and a 5-millimeter camera port is placed under direct vision. The appendix and abdominal contents are inspected laparoscopically. A Maryland grasper is inserted adjacent to the camera port directly through the fascia. Appendiceal length and cecal mobility are assessed. If the anatomy is not suitable for a single incision procedure, conversion to a standard laparoscopic MACE procedure is possible. Otherwise, the appendix is brought to the umbilical incision in concert with camera port removal. The tip of the appendix is secured with a tacking suture that aids in delivery. The entire appendicocecal junction can be delivered to allow for cecoplication or appendiceal tunneling if desired. The appendicocecal junction is returned to the abdomen. The distal tip of the appendix is excised extracorporeally to minimize peritoneal contamination. The appendix is spatulated and anastomosed to the “V” flaps, thus concealing the incision. A catheter is left in place for 2-3 weeks to minimize stenosis. Irrigations are initiated on postoperative day 1.
With appropriate patient selection to ensure sufficient appendiceal length and cecal mobility, a single incision laparoscopic-assisted MACE procedure can be performed by the pediatric urologist using standard pediatric laparoscopic equipment. No abdominal defects result beyond the umbilically-seated cutaneous appendicostomy. To date, we have performed this procedure on 5 pediatric patients without any intraoperative or postoperative complications. It allows for early postoperative bowel irrigation and can be performed as an outpatient procedure. Cecoplication and subcutaneous appendiceal tunneling are possible.
The single incision laparoscopic-assisted MACE procedure can be performed by the pediatric urologist with standard pediatric laparoscopic equipment. The cosmetic appearance is unsurpassed and benefits of minimally invasive surgery are maintained.