Laparoscopic antegrade continence enema in situ appendix procedure for refractory constipation and overflow fecal incontinence in children with spinabifida

Purpose: The antegrade continence enema procedure allows patients with neur ogenic bowel to administer large volume enemas through a right lower quadra nt stoma to flush the colon every other day. This procedure results in free dom from refractory constipation and diapers required by unexpected episode s of overflow fecal incontinence. We present a simplified laparoscopic tech nique using in situ appendix. Materials and Methods: A total of 6 male and 10 female children with a mean age of 12 years (range 4 to 21) and neurogenic bowel secondary to myelomen ingocele underwent the antegrade continence enema in situ appendix procedur e. The procedure was done with laparoscopic assistance, and associated with Other bladder and bladder outlet reconstructive surgery in 5 patients. In 3 patients, a purely laparoscopic antegrade continence enema in situ append ix procedure was performed. The appendix and cecum were mobilized, and the tip of the appendix was anastomosed directly to the skin of the right lower quadrant through 1 of the 5 mm. lower quadrant port sites. The continence mechanism is simply a function of the appendix length and the mucosal coapt ation of the appendiceal lumen. A 6Fr silicone Foley catheter is used to st ent the mucocutaneous anastomosis. Concomitant procedures included ileocyst oplasty, ileovesicostomy, sigmoidovesicostomy or uretercivesicostomy, and/o r pubovaginal sling done through a low Pfannenstiel incision after laparosc opic mobilization of the appendix and cecum. Results: The 3 patients treated with the laparoscopic antegrade continence enema procedure ate the day of surgery and were discharged home the next mo rning. Constipation and fecal incontinence resolved in all cases. All anteg rade continence enema stomas were catheterized easily with a 6 or 8Fr feedi ng tube and were continent. Complications in the 8 laparoscapic and laparos copic assisted cases included stomal stenosis requiring dilation in the off ice and obstructive volvulus associated with malrotation requiring segmenta l resection. Patient mothers in particular were gratified by this procedure at a mean followup of 1(1)/(2) years. Conclusions: The simplified antegrade continence enema in situ appendix pro cedure works well for refractory constipation and overflow fecal incontinen ce in children with neurogenic bowel secondary to spina bifida. Coaptation of the appendiceal lumen and use of small catheters allow for persistent co ntinence without a formal surgically constructed valve mechanism. The combi ned antegrade continence enema and either ileovesicostomy or sigmoidovesico stomy continent urinary diversion procedures allow children to control bowe l and bladder evacuation programs. A laparoscopic approach is reasonable pa rticularly in cases requiring no other procedures.