A NOVEL APPROACH TO THE LAPAROSCOPIC ANTEGRADECONTINENCE ENEMA PROCEDURE: INTRACORPOREAL AND

EXTRACORPOREAL TECHNIQUES

PASQUALE CASALE,* RICHARD W. GRADY, WALDO C. FENG, BYRON D. JOYNERAND MICHAEL E. MITCHELL

From the Children’s Hospital and Regional Medical Center, University of Washington, Seattle, Washington

ABSTRACT

Purpose: The use of laparoscopic techniques in the construction of an antegrade continenceenema (ACE) channel is evolving as a minimally invasive procedure that attempts to addressissues of morbidity commonly associated with the technique as originally described. Because ofour experience with “open” ACE construction, we maintain that true fecal continence of the ACEchannel requires more than dependence on the appendicocecal sphincteric mechanism. There-fore, we have implemented intracorporeal or extracorporeal suturing to create a reliable conti-nence mechanism.

Materials and Methods: We retrospectively reviewed 6 patients who underwent laparoscopicACE and compared the outcome to 20 consecutive conventional open ACE procedures. Outcomemeasures included operative time, perioperative pain control, length of hospital stay, channelleakage, stenosis and herniation.

Results: There was no significant difference in operative time between the laparoscopic andconventional groups. The laparoscopic approach was associated with decreased postoperativepain and hospital stay. Difference in complication rates for leakage, stenosis and herniation wasinsignificant.

Conclusions: Laparoscopic ACE, performed either completely intracorporeally or with laparo-scopic assistance as described, provides another option in the surgical armamentarium to createan antegrade continence enema with decreased postoperative morbidity.

KEY WORDS: adolescent, laparoscopy, appendix/surgery, fecal incontinence

The antegrade continence enema (ACE) was first describedin 1990 by Malone et al.1 It is used for intractable fecalincontinence and constipation of varying etiology. At ourinstitution ACE has been implemented mostly in the patientswith spina bifida and associated neurogenic bowel. It hasbeen demonstrated to be safe and effective with a high suc-cess rate.1, 2 However, the procedure is not without signifi-cant potential problems, such as stomal stenosis, stomal pro-lapse and stool leakage.3 The use of laparoscopic techniquesin construction of an ACE channel is evolving as a minimallyinvasive procedure that attempts to address issues of mor-bidity commonly associated with the technique as originallydescribed.3–6

The current laparoscopic ACE (LACE) continence mecha-nism has relied on the length of the appendix and the appen-dicocecal sphincter.3 Some studies have revealed that thereis no statistical significance in leakage rates regardless ofwhether the cecum is imbricated, but the subject still re-mains an area of controversy.3–6 Because of our experiencewith “open” ACE construction, we maintain that true fecalcontinence of the ACE channel requires more than depen-dence on the appendicocecal sphincteric mechanism. There-fore, we have implemented intracorporeal or extracorporealsuturing to create a reliable continence mechanism.

MATERIALS AND METHODS

Six patients underwent a laparoscopic ACE procedure withlaparoscopic valve reinforcement between 2001 and 2003.Patient age ranged from 14 to 18 years. All patients hadneurogenic bowel dysfunction related to spina bifida andwere on bowel enema programs. All sought independence ofcare. Four of the patients had ventriculoperitoneal shunts.Mean followup was 6 months (range 3 to 19).

A consecutive series of 20 patients who underwent theACE procedure in an open surgical fashion was used as ahistorical control group to compare safety and efficacy be-tween the 2 procedures. Of these 20 patients 18 had ventricu-loperitoneal shunts. None of the patients from either grouphad undergone previous bladder augmentation, and all pa-tients from both groups performed clean intermittent cathe-terization. Outcome measures included operative time, peri-operative pain control, length of hospital stay, channelleakage, stenosis and herniation. The Mann-Whitney andFisher exact tests were used for statistical comparison of the2 cohorts. A description of the laparoscopic technique follows.

Port placement. The patient is placed supine. A 3-porttransperitoneal approach is used, with the initial 10 mmport (port 1) placed at the inferior umbilical crease. Insuffla-tion to an abdominal pressure of 12 mm Hg is established.The umbilical port houses the laparoscope (5 mm, 0 degrees).Port 2 (10 mm) is placed at McBurney’s point. Port 3 (5 mm)is placed in the midline below the level of the umbilicus.Placement of ports 2 and 3 varies slightly depending onpatient body habitus.

Appendicocecal dissection. The surgical table is positionedso that the patient is in a 45-degree Trendelenburg positionwith a 45-degree lateral rotation so that the ipsilateral side is

Accepted for publication September 19, 2003.Study received institutional review board approval.* Requests for reprints: Division of Pediatric Urology, Children’s

Hospital and Regional Medical Center, 4800 Sand Point Way NE,P. O. Box 5371/6E-1, Seattle, Washington 98105 (telephone: 206-987-1270; FAX: 206-987-3925; e-mail: pat.casale@seattlechildrens.org).

0022-5347/04/1712-0817/0 Vol. 171, 817–819, February 2004THE JOURNAL OF UROLOGY® Printed in U.S.A.Copyright © 2004 by AMERICAN UROLOGICAL ASSOCIATION DOI: 10.1097/01.ju.0000108821.20709.52

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exposed. The small bowel is manipulated medially and thececum is identified. Once confirmation of an adequate appen-dix is obtained, the cecum is mobilized from its attachmentsto the body wall with cautery. The colon is mobilized approx-imately one-third toward the hepatic flexure, just enough toallow mobilization of the cecum to the anterior abdominalwall during insufflation.

The appendiceal mesentery is freed with sharp dissectionand hook electrocautery at the base of the cecum, avoidinginjury to the appendiceal artery (fig. 1). The serosa at theappendicocecal junction is incised with endoscopic scissors ina Y shape at the base of the appendix extending along thetinea, leaving the mucosal lining intact. Three-zero silk isthen used to imbricate the serosa onto the appendix, rein-forcing the valve mechanism (fig. 2). The appendix is thengrasped with an endoscopic Babcock clamp and deliveredthrough the umbilical port. The abdomen is desufflated. Thetip of the appendix is then transected and cannulated with an8Fr pediatric feeding tube to verify patency. The feeding tubeis then left indwelling.

Externalization of appendix. A skin flap is fashioned in a Vconfiguration at the umbilicus, incorporating the incisionmade for the port (fig. 3). A stoma is created with this flapthrough the existing fascial defect of the 10 mm port. The

FIG. 1. Appendiceal mesenteric dissection

FIG. 2. Three-zero silk is used to imbricate serosa onto appendix,reinforcing valve mechanism.

FIG. 3. Abdominal wall at level of umbilicus shows delineation ofV-flap incision (broken lines) incorporated by umbilical port.

FIG. 4. Laparoscopic view of cecum fixed to right anterolateralabdominal wall.

FIG. 5. Externalized appendicocecal junction via umbilical portdemonstrates imbrication.

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feeding tube is removed and reinserted through the stoma toensure patency and ease of passage. The cecum is then irri-gated to verify continence. The feeding tube is reinserted andsecured to the abdominal wall.

Fixation of cecum. After the appendix has been external-ized the abdomen is insufflated once again. The cecum isfixed to the right anterolateral abdominal wall with 2-zerointracorporeal polyglactin sutures (fig. 4).

Extracorporeal technique. If intracorporeal suturing is notan option, the appendix and base of the cecum can be exter-nalized via the umbilical port (fig. 5). For this approach a 12mm trocar should be used at the umbilicus. Once the appen-dix and cecum are externalized, the valve reinforcement canbe performed as in the open technique.1 Next, the cecum isgrasped with a Babcock clamp and tacked to the anteriorabdominal wall via the remaining 10 mm port site using 2separate 2-zero polyglactin sutures.

RESULTS

Mean operative time was 118 minutes for the laparoscopicgroup and 121 minutes for the historical control group. Therewas no significant difference in operative time between the 2groups (Mann-Whitney test, p � 0.5029). The laparoscopicapproach was associated with decreased postoperative pain(Fisher’s exact test, p � 0.001), as well as hospital stay(Mann-Whitney test, p � 0.0008, table 1). Table 2 outlinesthe complication rates of leakage, stenosis and herniation forthe 2 groups.

DISCUSSION

Appropriate patient selection is paramount in the successof the ACE procedure. It has been reported that patients withspina bifida and those with rectal or anal incontinence havebetter success with this procedure than patients who arechronically constipated.6 A relative contraindication, as inmost elective surgical cases, would be any indication of non-compliance.

Unless the umbilicus is planned for future bladder access,we believe that externalization of the stoma at the level of theumbilicus reliably gives an excellent cosmetic result.7 The 1cm umbilical fascial defect ensures blood flow to the catheter-izable channel and prevents herniation of intra-abdominalcontents. Our preliminary and intermediate data for stomalstenosis, herniation and leakage appear promising comparedto a historical control group of 20 consecutive patients whounderwent the ACE procedure in an open surgical fashion.The need for oral narcotics after discharge home, which cancontribute to constipation, may be eliminated. Longer fol-lowup and more cases are needed to assess the preservationof patency and continence with the laparoscopic technique.The statistical difference in the overall complication rate isnot significant due to the statistically low power of thegroups.

We believe that LACE can be done safely in patients withventriculoperitoneal shunts, since the appendix is incisedand cannulated extracorporeally. This approach decreasesthe potential risk of stool spillage. It is controversial as towhether stomal leakage would be prevalent without cecalimbrication. Imbrication of the cecal wall as initially de-scribed has been used with reproducible success.3–6

Previous LACE approaches are described as either laparo-scopic assisted or without incision of the cecal serosa withimbrication.3–9 The technique we describe is a novel ap-proach to LACE. It incorporates a completely laparoscopicapproach with intracorporeal techniques for incision and im-brication of the cecal serosa to create a valve mechanism. Thelaparoscopically reinforced valve mechanism appears to par-allel what has been described for the open technique.

CONCLUSIONS

A surgical procedure must prove to be feasible, safe andeffective. Advancement in minimally invasive techniques haspermitted extension of laparoscopic indications for the per-formance of complex reconstructive procedures.8, 9 As instru-mentation and techniques continue to be refined, the indica-tions for laparoscopy will continue to expand. Experiencedlaparoscopists can perform the LACE procedure safely. Thelearning curve is negligible, since the procedure uses laparo-scopic skills already mastered by the surgeons.

Future studies will include larger cohorts with longer fol-lowup, and should include postoperative quality of life con-cerns. We will continue to implement this technique in pa-tients who meet the criteria for ACE, so that they may benefitfrom the laparoscopic approach.

REFERENCES

1. Malone, P. S., Ransley, P. G. and Kiely, E. M.: Preliminaryreport: the antegrade continence enema. Lancet, 336: 1217,1990

2. Gerharz, E. W., Vik, V., Webb, G. and Woodhouse, C. R.: The insitu appendix in the Malone antegrade continence enema pro-cedure for faecal incontinence. Br J Urol, 79: 985, 1997

3. Karpman, E., Das, S. and Kurzrock, E. A.: Laparoscopic ante-grade continence enema (Malone) procedure: description andillustration of technique. J Endourol, 16: 325, 2002

4. Webb, H. W., Barraza, M. A. and Crump, J. M.: Laparoscopicappendicostomy for management of fecal incontinence. J Pe-diatr Surg, 32: 457, 1997

5. Philip, I. and Nicholas, J. L.: Laparoscopic appendicostomy formanagement of fecal incontinence. J Pediatr Surg, 33: 670,1998

6. Cromie, W. J., Goldfischer, E. R. and Kim, J. H.: Laparoscopiccreation of a continent cecal tube for antegrade colonic irriga-tion. Urology, 47: 905, 1996

7. Ellsworth, P. I., Webb, H. W., Crump, J. M., Barraza, M. A.,Stevens, P. S. and Mesrobian, H.-G. J.: The Malone antegradecolonic enema enhances the quality of life in children under-going urological incontinence procedures. J Urol, 155: 1416,1996

8. Moore, R. G., Kavoussi, L. R., Bloom, D. A., Bogaert, G. A.,Jordon, G. H., Kogan, B. A. et al: Postoperative adhesionformation after urological laparoscopy in the pediatric popu-lation. J Urol, 153: 792, 1995

9. Hedican, S. P., Schulam, P. G. and Docimo, S. G.: Laparoscopicassisted reconstructive surgery. J Urol, 161: 267, 1999

TABLE 1. Hospital length of stay and analgesia

ACE (No. pts) Procedure Mean Hrs Patient ControlledAnalgesia (No. pts)

No. Oral Narcotic� Ketorolac

No. IntravenousNarcotic as Needed

Hrs Length ofHospital Stay

Open (20) 41 (20) 0 18 78Laparoscopic antegrade con-

tinence enema (6)10 (2) 4 3 53

p Value 0.001 0.001 0.062 0.0008

TABLE 2. Complications

ACE Procedure No. Leakage No. Stenosis

Open 3 2Laparoscopic antegrade continence enema 0 0

p Value 0.298

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