Initial Use of LESS for the ACE Malone Procedure in Children
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Pediatric Case Report Initial Use of LESS for the ACE Malone Procedure in Children George Chiang and Timothy Fairbanks The Malone antegrade continence enema is effective in improving fecal continence in neurogenic bowel. We were able to perform this procedure laparoscopically via a single incision in a patient with spina bifida and fecal incontinence who did not require bladder reconstruction. UROLOGY 80: 717–718, 2012. © 2012 Elsevier Inc. T he Malone antegrade continence enema (ACE) has been shown to be effective in improving fecal continence among patients with spina bifida. Af- ter its initial report in 1990, there have been multiple modifications of the technique. In a patient with spina bifida and fecal incontinence who did not require bladder reconstruction, we were able to perform this as a laparo- endoscopic single-site (LESS) procedure without use of a commercial multiport. The operative time was 67 min- utes. There was minimal blood loss and no perioperative complications. CASE REPORT A 7-year-old female with a history of lipomyelomenin- gocele at the sacral level presented with fecal inconti- nence and recurrent urinary tract infections. She had undergone removal of the lipoma and untethering of her cord at 3 months. She did not require a ventriculoperi- toneal (VP) shunt. She was successfully dry and indepen- dent with clean intermittent catheterization (CIC) and urodynamics (UDS) showed adequate bladder capacity and low pressures. Despite attempts at an aggressive bowel regimen of oral medications and a cone enema, the patient continued to have constipation and intermittent fecal incontinence requiring diapers. As a result, a LESS ACE procedure was recommended. The patient was admitted for a bowel preparation 1 day before surgery. A 2-cm longitudinal skin incision through the umbilicus was created. Pneumoperitoneum was per- formed using a Veress needle via the intact umbilical ring. A 5-mm trocar was then placed under direct vision through the ring. The appendix was easily visualized in the right lower quadrant. A #11 blade was then used to create 2 small fascial incisions above and below the 5-mm trocar. A 3-mm grasper was placed through the inferior incision and a 45° bariatric length telescope with a right angle light cord adapter was placed via the superior incision (Fig. 1). The grasper and the telescope remained intracorporeal throughout the procedure. Cleaning of the telescope was performed as needed against the anterior abdominal wall. A harmonic scalpel was used via the 5-mm trocar to assist with mobilization of the appendix and cecum off the retroperitoneum. The appendix was then delivered via the trocar site. Plication was not performed and 4-0 Vicryl sutures were used to secure the serosa of the appendix at the fascial level. The appendix was spatulated along its antimesenteric border and an adjacent V-skin flap was created with the initial skin incision. After ensuring passage and placement of a 10-Fr Foley catheter, the mucocutaneous anastomosis was per- formed with multiple 5-0 Vicryl sutures. The 2 additional fascial incisions were closed with interrupted 4-0 Vicryl and the remainder of the skin incision was closed with 5-0 Monocryl (Fig. 2). Operative time was 67 minutes. The patient started flushing per her ACE on postopera- tive day 1 with 60 mL of water. This was gradually increased on an outpatient basis to 480 mL daily over the course of 2 weeks with good effect. She was discharged home on postoperative day 2. She required no narcotic medications and her average FLACC score while admit- ted was 0.5. The ACE catheter was removed at 10 days. Six months later, she is currently out of diapers and her stoma is patent without leakage. Cosmetically, her ACE is well hidden at the umbilicus without any apparent scar. COMMENT After its initial report in 1990, 1 the success rate of the Malone ACE procedure in resolving fecal incontinence has been reported to be as high as 100%. 2 In patients who do not require a Mitrofanoff procedure for their bladder based on independence with CIC and UDS, the use of the appendix for an ACE is easily accomplished. Others have reported splitting the appen- dix for use as a Malone ACE and a Mitrofanoff, although this was not necessary in this patient. 3 It is our practice to have patients with VP shunts admitted for a bowel prep before bowel or bladder reconstruction because of Financial Disclosure: The authors declare that they have no relevant financial interests. From UCSD Pediatric Urology and Pediatric Surgery, Rady Children’s Hospital, San Diego, California Reprint requests: George Chiang, M.D., 7930 Frost Street #300, San Diego, CA 92123. E-mail: [email protected] Submitted: December 26, 2011, accepted (with revisions): January 23, 2012 © 2012 Elsevier Inc. 0090-4295/12/$36.00 717 All Rights Reserved doi:10.1016/j.urology.2012.01.031
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Transcript of Initial Use of LESS for the ACE Malone Procedure in Children
Pediatric Case Report
Initial Use of LESS for theACE Malone Procedure in ChildrenGeorge Chiang and Timothy Fairbanks
The Malone antegrade continence enema is effective in improving fecal continence in neurogenic bowel. We were ableto perform this procedure laparoscopically via a single incision in a patient with spina bifida and fecal incontinence who
did not require bladder reconstruction. UROLOGY 80: 717–718, 2012. © 2012 Elsevier Inc.The Malone antegrade continence enema (ACE)has been shown to be effective in improving fecalcontinence among patients with spina bifida. Af-
ter its initial report in 1990, there have been multiplemodifications of the technique. In a patient with spinabifida and fecal incontinence who did not require bladderreconstruction, we were able to perform this as a laparo-endoscopic single-site (LESS) procedure without use of acommercial multiport. The operative time was 67 min-utes. There was minimal blood loss and no perioperativecomplications.
CASE REPORTA 7-year-old female with a history of lipomyelomenin-gocele at the sacral level presented with fecal inconti-nence and recurrent urinary tract infections. She hadundergone removal of the lipoma and untethering of hercord at 3 months. She did not require a ventriculoperi-toneal (VP) shunt. She was successfully dry and indepen-dent with clean intermittent catheterization (CIC) andurodynamics (UDS) showed adequate bladder capacityand low pressures. Despite attempts at an aggressivebowel regimen of oral medications and a cone enema, thepatient continued to have constipation and intermittentfecal incontinence requiring diapers. As a result, a LESSACE procedure was recommended.
The patient was admitted for a bowel preparation 1 daybefore surgery. A 2-cm longitudinal skin incision throughthe umbilicus was created. Pneumoperitoneum was per-formed using a Veress needle via the intact umbilicalring. A 5-mm trocar was then placed under direct visionthrough the ring. The appendix was easily visualized inthe right lower quadrant. A #11 blade was then used tocreate 2 small fascial incisions above and below the 5-mmtrocar. A 3-mm grasper was placed through the inferior
Financial Disclosure: The authors declare that they have no relevant financial interests.From UCSD Pediatric Urology and Pediatric Surgery, Rady Children’s Hospital, San
Diego, CaliforniaReprint requests: George Chiang, M.D., 7930 Frost Street #300, San Diego, CA
92123. E-mail: [email protected]: December 26, 2011, accepted (with revisions): January 23, 2012
© 2012 Elsevier Inc.All Rights Reserved
incision and a 45° bariatric length telescope with a rightangle light cord adapter was placed via the superiorincision (Fig. 1). The grasper and the telescope remainedintracorporeal throughout the procedure. Cleaning of thetelescope was performed as needed against the anteriorabdominal wall. A harmonic scalpel was used via the5-mm trocar to assist with mobilization of the appendixand cecum off the retroperitoneum. The appendix wasthen delivered via the trocar site. Plication was notperformed and 4-0 Vicryl sutures were used to secure theserosa of the appendix at the fascial level. The appendixwas spatulated along its antimesenteric border and anadjacent V-skin flap was created with the initial skinincision. After ensuring passage and placement of a 10-FrFoley catheter, the mucocutaneous anastomosis was per-formed with multiple 5-0 Vicryl sutures. The 2 additionalfascial incisions were closed with interrupted 4-0 Vicryland the remainder of the skin incision was closed with5-0 Monocryl (Fig. 2). Operative time was 67 minutes.The patient started flushing per her ACE on postopera-tive day 1 with 60 mL of water. This was graduallyincreased on an outpatient basis to 480 mL daily over thecourse of 2 weeks with good effect. She was dischargedhome on postoperative day 2. She required no narcoticmedications and her average FLACC score while admit-ted was 0.5. The ACE catheter was removed at 10 days.Six months later, she is currently out of diapers and herstoma is patent without leakage. Cosmetically, her ACEis well hidden at the umbilicus without any apparent scar.
COMMENTAfter its initial report in 1990,1 the success rate of theMalone ACE procedure in resolving fecal incontinencehas been reported to be as high as 100%.2
In patients who do not require a Mitrofanoff procedurefor their bladder based on independence with CIC andUDS, the use of the appendix for an ACE is easilyaccomplished. Others have reported splitting the appen-dix for use as a Malone ACE and a Mitrofanoff, althoughthis was not necessary in this patient.3 It is our practiceto have patients with VP shunts admitted for a bowel
prep before bowel or bladder reconstruction because of0090-4295/12/$36.00 717doi:10.1016/j.urology.2012.01.031
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the concern for VP shunt infection and the ease ofstarting ACE irrigations postoperatively. We also do notplicate the base of the cecum during this procedure andleave the appendix in situ because we feel it is notnecessary for continence and may impinge on the appen-diceal blood supply.4 We have not found any problems
Figure 1. Single incision with midline 5-mm trocar workingort. Superiorly placed telescope and inferior grasper re-ain intracorporeal throughout the dissection. (Color ver-
ion available online.)
Figure 2. Immediate postoperative appearance. ACE cath-ter remains for 10 days. (Color version available online.)
with stomal leakage in patients who have an ACE per-
718
formed in this manner via a conventional laparoscopic oropen approach.
LESS procedures have continued to increase in volumeamong adult urology practitioners.5 A variety of proce-ures have been reported in the pediatric literature afterhe first single-port nephrectomy was performed.6 This ishe first report detailing the use of this approach for anppendicostomy. Although there is no definitive evi-ence that there is a distinct advantage with LESS com-ared with conventional laparoscopy or open surgery inegards to surgical morbidity or complications,7 there is a
proven tendency for younger patients to desire improvedcosmesis in benign conditions.8 We feel that the LESSACE is a straightforward approach to a simple urologicalreconstruction. It has the added benefit of superior cos-metic outcome when compared with current approachesand has been adapted from the current method of single-incision laparoscopic appendectomy at our institution. Itdoes not require the use of additional specialized instru-ments or a multiport, and in fact it uses less overallequipment with regards to trocars versus conventionallaparoscopy. This technique continues to push LESS inpediatric urology as a viable method for simple recon-structive efforts.
References1. Malone PS, Ransley PG, Kiely EM. Preliminary report: the ante-
grade continence enema. Lancet. 1990;336:1217-1218.2. Nanigian DK, Kurzrock EA. Intermediate-term outcome of the sim-
plified laparoscopic antegrade continence enema procedure: less isbetter. J Urol. 2008;179:299-303.
3. Kajbafzadeh AM, Chubak N. Simultaneous Malone antegrade con-tinent enema and Mitrofanoff principle using the divided appendix:report of a new technique for prevention of stoma complications.J Urol. 2001;165:2404-2409.
4. Van Savage JG, Yohannes P. Laparoscopic antegrade continenceenema in situ appendix procedure for refractory constipation andoverflow fecal incontinence in children with spina bifida. J Urol.2000;164:1084-1087.
5. Kaouk JH, Autorino R, Kim FJ, et al. Laparoendoscopic single-sitesurgery in urology: worldwide multi-institutional analysis of 1076cases. Eur Urol. 2011;60:998-1005.
6. Park YH, Kang MY, Jeong MS, et al. Laparoendoscopic single-sitenephrectomy using a homemade single-port device for single-systemectopic ureter in a child: initial case report. J Endourol. 2009;23:833-835.
7. Woldrich JM, Holmes N, Palazzi-Churas K, et al. Comparison oflaparoendoscopic single-site, conventional laparoscopic, and opennephrectomy in a pediatric population. Urology. 2011;78:74-77.
8. Park SK, Olweny EO, Best SL, et al. Patient-reported body imageand cosmesis outcomes following kidney surgery: comparison oflaparoendoscopic single-site, laparoscopic, and open surgery. Eur
Urol. 2011;60:1097-1104.UROLOGY 80 (3), 2012
