JOURNAL OF ENDOUROLOGYVolume 16, Number 6, August 2002 Mary Ann Liebert, Inc.
TECHNIQUES IN ENDOUROLOGY
Laparoscopic Antegrade Continence Enema (Malone)Procedure: Description and Illustration of Technique*
EDWARD KARPMAN, M.D., SAKTI DAS, M.D., and ERIC A. KURZROCK, M.D., FAAP
The antegrade continence enema (ACE Malone) procedure has improved the lives of many patients who strug-gle with intractable forms of constipation. We describe a laparoscopic approach to this technique and reviewthe literature.
THE MANAGEMENT OF CHRONIC CONSTIPATIONand encopresis in patients with neurogenic bowel and othercolonic motility disorders has traditionally relied on laxatives,enemas, digital stimulation, and manual disimpaction. Evenwith the strictest of regimens and the most diligent patients, en-copresis, constipation, or both often persist.
In 1990, Malone and associates first described the antegradecontinence enema (ACE) procedure using the appendix.1 Sev-eral modifications have been described since. This operationhas improved the lives of many patients who struggle with in-tractable forms of constipation. Complete resolution of fecalsoiling has been reported in as many as 95% of patients.2 Pa-tient satisfaction with the ACE procedure is very high, and therisk of complications is low.3
More recently, laparoscopic ACE (LACE) has been reported.The LACE may offer the advantages of a shorter hospital stay,faster recovery, less postoperative pain, and better cosmesis.Minimizing postoperative ileus is especially important in thesepatients with bowel motility problems. Success with this ap-proach relies on proper patient selection and appropriate plan-ning and performance of the laparoscopic surgery.
The ideal candidate for LACE is one who suffers from in-tractable constipation or encopresis and has failed multiple
bowel evacuation regimens. For those requiring assistance, areliable caretaker is paramount. Preferably, the patients fecalsoiling should be the result of neurogenic bowel or poor distalrectal or anal competence. Prior abdominal surgery may be arelative contraindication.
The patient is prepared with mild laxatives 3 days prior tosurgery and a full mechanical bowel preparation the day beforesurgery. Broad-spectrum antibiotics are given perioperatively.The patient is induced with a general anesthetic, and an oro-gastric tube and Foley catheter are placed. The table is tilted tothe patients left and with the head down.
An inverted-V incision is made in the umbilicus to raise aflap for subsequent stomal construction. A 5-mm trocar is in-serted directly beneath the skin flap and secured in place withtwo fascial sutures. After the pneumoperitoneum has been es-tablished and the camera inserted, two additional 3.5- or 5-mmtrocars are placed lateral to the rectus muscle at the level of theumbilicus.
Localization and Mobilization of Appendix
The appendix is mobilized out of the right lower quadrantusing grasping forceps. Adhesions may obscure the appendix,especially in children with a ventriculoperitoneal shunt. The tipof the appendix is grasped and stretched to demonstrate itslength and caliber (Fig. 1A). The mesentery and vasculature are
Department of Urology, Childrens Hospital, University of California Davis School of Medicine, Sacramento, California.* A video illustrating certain steps in this technique is included with the issue and is available online at www.liebertpub.com/end/video.
inspected. Often, separate arteries may be evident supplying theproximal and distal appendix (Fig. 1B). To straighten a longappendix for catheterization, the distal artery may be sacrificed(Fig. 1C). The pneumoperitoneum will distort the apparentproximity of the cecum to the abdominal wall. Release of thepneumoperitoneum will reveal the appendiceal redundancy(Fig. 2).
Usually, only 1 to 2 cm of intra-abdominal appendix is re-quired for prevention of stomal leakage. Appendiceal coapta-tion and the cecoappendiceal sphincter will provide adequateresistance.3 We make every attempt to position the stoma in theumbilicus. If necessary, the right side of the colon can be mo-bilized along the line of Toldt. If the appendix still does notreach the umbilicus, the stoma can be created in the right up-per or lower quadrant.
Creation of Anastomosis
After adequate mobilization of the appendix, the camera isswitched to the left port. The appendix is clamped with grasp-ing forceps and brought out through the umbilical wound afterthe port is removed. The pneumoperitoneum is released, andthe appendix is divided at the level of the skin. Prior to com-plete division of the appendix, the appendicular artery is lig-
ated at skin level with absorbable suture. The appendix is in-tubated with an 8F feeding tube and spatulated on the antime-senteric border. The umbilical V-flap is sewn into the spatula-tion, and the stoma is matured with absorbable suture.
An appendiceal catheter is left in situ for approximately threeweeks (Fig. 3). The catheter is removed in clinic, and the pa-tient is instructed on catheterization and enema technique. Westart at a volume of 250 mL and instruct the patients to increasethe volume gradually until they are able to evacuate all of theircolonic contents in one sitting. This usually requires a volumeof 500 to 1000 ml. Placement of the enema and complete evac-uation of the colon can take as long as an hour. In general, en-emas are placed daily, but some patients are satisfied withevery-other-day enemas.
ROLE IN UROLOGIC PRACTICE
The ACE procedure has undergone many revisions since itsinception in 1990. The original description by Malone and as-sociates utilized appendiceal reversal, whereas more recent se-
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FIG. 1. Mobilization and preparation of appendix. (A) Tip ofappendix being grasped. (B) Uncoiling of appendix and iden-tification of arteries (d5 distal artery; p 5 proximal artery;tip5 tip of appendix). (C) Division of distal artery (d).
ries use in situ appendix with or without cecal plication. Theknowledge that use of the appendix in situ without plication re-sults in low rates of stomal leakage opened the door for the lap-aroscopic approach. Cromie and colleagues4 published the firstreport of LACE in dogs. The results of clinical series arepromising,58 but more controlled studies comparing LACEwith open surgery need to be done.
The indications for surgery and proper patient selection arecritical. Previously reported series have shown better successin patients with spina bifida and those with distal rectal andanal incompetence than in patients with chronic constipationfor other reasons.9 Children under the age of 5 years may notbe able to remain on the toilet for the time required to evacu-ate all of the colonic contents. Finally, the dedication of the pa-tient or caretaker must be scrutinized. People who are poorlycompliant with a regular bowel regimen will not be successfulin remaining clean and dry after LACE.10
Many modifications to the ACE Malone procedure have been
described. These include cecal plication, appendix reversal, for-mation of a cecal tube using the Boari principle, formation ofan intestinal conduit using the Monti principle, and split ap-pendix surgery.1114 We perform an in situ anastomosis of theappendix to the abdominal wall without any plication. Previ-ously, it had been suspected that stomal leakage would be morefrequent without plication. Studies have shown this not to betrue, with a reported leakage rate of only 6.7% with LACE8
compared with 6.6% with open ACE.15 We believe appendicealcoaptation and the preservation of the ceco-appendiceal sphinc-ter create adequate outlet resistance.
Some authors recommend forming the stoma on the rightlower abdomen.1,7 This approach requires less cecal mobiliza-tion and manipulation, theoretically reducing the risk of com-plications. We and others recommend using the umbilicus be-cause of the cosmetically appealing results.11,16 The umbilicallocation does not increase the risk of stomal stenosis for ACEor urinary diversion.16 We attempt to minimize stenosis by us-ing an inverted-V incision to inlay into the spatulated appen-dix. Other options include a VQZ incision or Y appendi-coplasty.10,17
The rate of stomal stenosis has been reported to be about30% with either laparoscopic or open ACE.8 The majority ofpatients are managed initially with dilatation. How many ofthese patients ultimately require surgical revision is unknown.
We begin using the ACE 3 weeks after surgery and recom-mend tap water because of its effectiveness and simplicity. Inthe Southhampton study, the most common washout regimenused was a phosphate enema,9,10 but this product has been re-ported as the cause of pain in 58% of the patients in the initial3 months of using the ACE. To overcome this problem, the au-thors reported using a liquorice root recipe. Other options in-clude Fletchers arachis-oil retention enema, saline, and warmtap water enemas.10,18 Fatal hypernatremia has been reportedas a result of using home-made saline solutions for colonicwashouts.19 Our clinical nurse specialist is closely involved inmonitoring the patients progress. Close postoperative follow-up is paramount to long-term success.
LAPAROSCOPIC ACE MALONE 327
FIG. 3. Well-concealed umbilical stoma intubated with cath-eter.
FIG. 2. Effect of pneumoperitoneum on relation of cecum to abdominal wall. (A) Extension of appendix (arrow) with pneu-moperitoneum (t 5 right trocar). (B) Extension of appendix after pneumoperitoneum is released.
The management of fecal soiling and