International Journal of Urology

(2003)

10,

401–403

Blackwell Science, LtdOxford, UKIJUInternational Journal of Urology0919-81722003 Blackwell Science Asia Pty LtdJuly 2003107401403Case Report

Laparoscopic antegrade continence enemaK Ameda

et al.

Correspondence: Kaname Ameda

MD

, Hokkaido MemorialHospital of Urology, North-40 East-1, Higashi-ku, Sapporo007-0840, Japan. Email: KanameAmeda@aol.com

Received 3 June 2002; accepted 20 January 2003.

Case Report

Laparoscopic antegrade continence enema procedure for fecal incontinence in a patient with spina bifida

KANAME AMEDA, HIDEHIRO KAKIZAKI, RINTARO MACHINO, HIROSHI TANAKA, TAKASHI SHIBATA AND TOMOHIKO KOYANAGI

Department of Urology, Hokkaido University Graduate School of Medicine, Sapporo, Japan

Abstract

We report a laparoscopic procedure for antegrade continence enema (LACE) that was performedsuccessfully in 39-year-old man patient with spina bifida suffering from severe fecal incontinence.The patient had been receiving regular follow-up at our clinic. He desired the antegrade continenceenema procedure to improve his intractable fecal incontinence with a less invasive procedure.

Following the placement of the first port at the umbilicus using an open access technique, twoadditional ports were introduced at the upper and lower abdomen in the midline. The appendix waslaparoscopically mobilized to the right lower abdomen and brought out through another port. Next,an

in situ

appendicocutaneostomy was created. The patient began oral intake the day after surgery.Initial irrigation was performed on the second postoperative day. Convalescence was quick and therewere no postoperative complications. Although a minor skin incision was required afterward forsuperficial stoma stenosis, the patient has been in a satisfactory condition with regular enemas.

Laparoscopic appendicocutaneostomy can be a reasonable surgical alternative for antegradecontinence stoma procedure. LACE has a clear advantage over conventional open procedures in viewof its less invasive nature and better cosmetic results.

Key words

appendix, constipation, fecal incontinence, laparoscopy.

Introduction

Fecal control is a major concern in patients with spinabifida. More than 50% of spina bifida patients sufferfrom intractable constipation and fecal incontinence.

1

Physicians paid little attention to this complicated prob-lem in the past, and therefore, it remained unresolvedfor decades. In 1990, Malone presented a novel surgicalsolution by constructing an appendicocutaneostomy forantegrade continence enema.

2

Curry

et al.

reported goodlong-term results in patients with poor fecal control,especially in children with spina bifida.

3

Indeed,Malone’s antegrade continence enema (MACE) is anoutstanding treatment option compared with otherconservative treatments. However, if MACE procedureis performed on its own, it requires an adequate lengthof laparotomy. Therefore, patients must accept some

potential complications including postoperative ileus.Recent advances in laparoscopic surgery have enabledus to apply this technique for MACE. Herein, we reportour experience of a laparoscopic MACE procedure(LACE) for a patient with spina bifida who sufferedfrom severe fecal incontinence.

Case report

A 39 year-old man with spina bifida had been followedup at our clinic with regular self-intermittent catheter-ization for neurogenic bladder dysfunction. Althoughhis urinary status was acceptable (except for occasionalepisodes of acute epidydimitis in the right side) hisquality of life had been compromised by severe fecalincontinence for decades. There had been no effectiveconservative therapy available in the past to improve hispoor fecal control. We recommended Malone’s ante-grade continence enema as a promising treatment toresolve his problem and improve his quality of life.However, he did not desire a major open surgery, but

402 K Ameda

et al.

wanted a less invasive procedure. Therefore, weexplained LACE to the patient and he agreed to theprocedure.

An appendicocutaneostomy was performed in July2000. Under general anesthesia, the patient was placedin a supine position with the right side of his body slightlyelevated. The first port (12mm) was placed at the umbi-licus using an open access technique, then two additionalports (5mm) were placed at the upper and lower abdomenin the midline (Fig.1). First, the appendix was identified,then the cecum and right colon were mobilized towardthe hepatic flexure. The appendix was carefullymobilized with well preserved blood supply to the rightlower abdomen. A 5mm port was inserted at the lowerquadrant abdomen (McBurney’s point) so that the tip ofthe appendix was carried straight out through the portsite (Fig.2).

In situ

appendicocutaneostomy was per-formed by spatulating the tip of the appendix withtension-free anastomosis to the port site skin using 4–0absorbable sutures. The cecum was laparoscopicallyfixed at the abdominal wall by an intracolporeal anchorsuturing using 3–0 absorbable sutures. A 10Fr. siliconFoley catheter was placed through the stoma for post-operative antegrade enema. Right vasectomy was per-formed laparoscopically as an additional procedure toprevent further epidydimitis. Total operation time was3h with estimated blood loss less than 20mL.

The patient began oral intake the day after surgery.No painkillers were required postoperatively. Initial irri-gation was performed on the second postoperative day.The catheter in the stoma was removed 2 weeks after

the operation. Daily calibration of the stoma was insti-tuted using 8 and 10Fr. catheters. Antegrade enema wasperformed with 300mL of saline or tap water everyother day, resulting in the elimination of impacted stooland fecal incontinence. Although a minor skin incisionwas required for a superficial stoma stenosis 7 monthsafter surgery, the patient has been gratified with diaper-free life under regular enema, as well as an excellentbody image (Fig.3).

Fig. 1

Position of the four ports in laparoscopic ante-grade continence enema procedure for fecal incontinencein a patient with spina bifida.

Fig. 2

Laparoscopic antegrade continence enema proce-dure for fecal incontinence in a patient with spina bifida.The appendix (arrow) was brought out through the abdom-inal wall. (*) cecum.

Fig. 3

Abdomen of a patient with spina bifida who under-went laparoscopic antegrade continence enema procedurefor fecal incontinence. Arrow indicates the stoma.

Laparoscopic antegrade continence enema 403

Discussion

Antegrade continence enema was first introduced byMalone in 1990.

2

Excellent long-term outcomes havebeen reported in children with anorectal dysfunctiondue to an anorectal anomaly, Hirschsprung disease andspina bifida. Curry reported 273 cases of MACE, 79%of which were successfully treated.

3

There is no doubtthat fecal control is highly improved in patients whoundergo MACE. However, the MACE procedure gener-ally requires a long midline or pararectal incision toadequately mobilize the right colon, especially whenbowel adhesion secondary to prior open surgery ispresent. Potential bowel complications like postopera-tive ileus are also obstacles in patients’ acceptance ofthe MACE procedure.

Recent advances in the field of laparoscopic surgeryhave had a significant impact on modern urology.Laparoscopy-assisted technique or total laparoscopicprocedure for MACE has been reported by severalinstitutes.

4–6

LACE is supposed to be a better surgicalalternative because it is a simple and less complicatedprocedure. Lynch

et al.

performed LACE in 30 patientswho were between 5 and 16 years of age, and fecalcontrol was improved in 90% of these patients.

6

In 1997, Gerharz

et al

. first reported an

in situ

appen-dix procedure with a successful outcome.

7

They simplytunnelled the appendix into the taenia of the cecumwithout detachment. In 2000, Van Savage and Yohannesfirst reported a laparoscopic

in situ

appendix procedureas a further simplified technique.

8

They demonstrated anexcellent surgical outcome by simply mobilizing andbringing the appendix through the right lower abdomenusing a laparoscopic technique. Severe fecal inconti-nence was cured in all cases, while postoperative com-plications were experienced in only two cases (stomalstenosis in one, and colic distortion in the other) withoutstomal leakage. Although Malone has stressed theimportance of antireflux mechanism,

1

an

in situ

appen-dix procedure clearly meets the surgical goal because itis simple, less invasive and effective. This less compli-cated technique promises quick convalescence, fewerwound complications and an appealing cosmetic result.The continence mechanism of

in situ

appendix conduitis thought to depend on the length of the appendix andthe coaptated lumen.

There have been some reports of considerable com-plications associated with MACE, including stomalstenosis, stomal leakage and adhesive ileus.

3

Althoughsimilar complications could be associated with LACE,

in the long-term, it has been suggested that laparoscopicsurgery is likely to decrease the incidence of boweladhesion formation.

9

Another less invasive surgicalalternative is a percutaneous button cecostomy with orwithout endoscopy guidance.

10,11

Although it requires adevice placement, it might have some advantage inpatients without an adequate length of appendix forconduit.

Although additional series with longer follow-upperiods are required, the LACE procedure could be areasonable surgical alternative for patients with spinabifida who have refractory fecal incontinence and con-stipation. When an appendix stoma is indicated as a soleprocedure, LACE has a clear advantage over conven-tional open MACE because of its less invasive natureand better cosmetic results.

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