LAPAROSCOPIC CREATION OF A CONTINENT CECAL TUBE FOR ANTEGRADE COLONICIRRIGATION

Objectives, The antegrade continence enema (ACE) procedure has been us ed for the treatment of overflow fecal incontinence or constipation in patients with spina bifida. The procedure requires an appendiceal rei mplantation into the cecum with creation of a continent abdominal stom a for antegrade colonic washout. To preserve the appendix for potentia l use in urinary diversion, we developed two surgical techniques for t ubularizing an antimesenteric cecal segment to use in place of the app endix. Methods, The surgery was performed in 6 dogs. The first two pro cedures used an open surgical technique through a 10-cm midline laparo tomy. The cecum was isolated, and a small cecotomy was made. A 10F red rubber catheter was introduced into the cecotomy, and a 4-cm length o f cecum was tubularized along its antimesenteric border with a gastroi ntestinal anastomosis stapler over the catheter. A nipple was created at the base of the tube to enhance continence, and the tubular segment was brought through the lower abdominal wall to create a catheterizab le stoma. After our success, four subsequent procedures were performed laparoscopically to create the same tubularized cecal segment. A 4-cm antimesenteric tubularized cecal segment with sufficient lumen to acc ommodate a 10F to 12F catheter was constructed using a laparoscopic ga strointestinal anastomosis stapler. Rather than creating a nipple at t he base of the tubular segment, continence of the stoma was achieved b y tunneling the cecal tube through a 2-cm lower quadrant subcutaneous tunnel. A flush stoma was then created and secured to the skin. Result s, Stoma viability was grossly confirmed in all 6 dogs during the post operative period, with no incidence of bower obstruction. Slight fecal leakage through the stoma was observed in 1 dog with a laparotomy but not in those with laparoscopy. Catheterization was easily performed i n all dogs with a 10F red rubber catheter during the postoperative per iod. The dogs were killed on postoperative day 10, and gross anatomic and histologic examination of the cecal segment confirmed luminal pate ncy and viability. Conclusions. Open and laparoscopic continent cecost omies were successfully constructed in a canine model and are likely t o be applicable to humans with neuropathic constipation.