Laparoscopic continent appendicocecostomy
Most of the previously reported techniques to construct a laparoscopic appendicocecostomy (LA) for antegrade continent enemas (ACE) do not create a continence mechanism with a submucosal tunnel, which carries the risk of leakage of stool. We report a technique to construct a LA for ACE, which creates a submucosal tunnel, mimicking the open technique (Modified Malone).
Material and methods
The appendix was isolated and the cecum mobilized. A 4 cm seromuscular incision was done from the base of the appendix along the tenia and the proximal appendix was placed in a submucosal tunnel created by reapproximatiion of the seromuscular layer of the cecum with interrupted sutures. Under laparoscopic vision the appendix was brought out through the umbilical site and anastomosed to the V flap previously prepared in the umbilical skin. A catheter was left in place for four weeks.
There were two patients, 8.5 and 8.6 years old. Diagnosis were neurogenic bowel dysfunction secondary to lipomeningocele and tethered spinal cord in 1 child and high imperforated anus and tethered spinal cord in the other. Mean operative time was 3.5 hours. Blood loss was negligible. There were no complications. Patients were discharge home at 3 and 4 days postoperatively. At 9 and 14 months after surgery there has not been difficulties with catheterization or stoma related complications. Both patients are compliant with antegrade enemas, continent of stool and very satisfied with the procedure.
The appendicocecostomy for ACE created with a submucosal tunnel and located at the umbilicus with open surgery provides a concealed stoma with easy access and no leaking problems. Following the same principles we were able to reproduce these technique laparoscopically to provide a reliable channel with the advantages of minimal invasiveness and improved cosmesis.