br In patients with spina bifida

In patients with spina bifida and spinal cord injury, fecal incontinence is a serious issue that can impair activities of daily living and patient self-esteem. To address this Malone et al. first described the Antegrade Continence Enema (ACE) procedure in 1990 [1], which achieves continence by allowing patients to evacuate their colon at appropriate, pre-determined times. The operation can be performed concurrently with urinary tract reconstruction including bladder augmentation, bladder neck procedures and a continent catheterizable channel (Mitrofanoff) [2]. Often an intra-operative decision has to be made as to the length and viability of the l-ascorbic acid in terms of adequacy for both Mitrofanoff and ACE-Malone catheterizable channel, or whether an alternate enteric conduit is performed (Monti, cecal flap) with increased complication rates [3]. ACE can also be performed through a cecostomy appliance such as a button or pigtail tube which can be accomplished simply and safely by laparoscopy [4], [5], [6]. Although cecostomy appliances eliminate the risk of stomal stenosis [7], other complications occur including stool leakage and site pain/discomfort in up to 30% [5]. Patients also have to wear an appliance and submit to regular changes. A significant percentage of patients are sufficiently bothered by the appliance and complications that some pursue conversion to ACE-Malone. In their series Hoy et al. [8] note that 8.7% of patients with cecostomy appliance in their database went on to have conversion to ACE-Malone. Herein, we describe robotic-assisted laparoscopic conversion of cecostomy button to ACE that, to our knowledge, has not been described previously.
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Results:
Discussion: With many surgeons now performing ACE procedures using a cecostomy appliance for pediatric patients, those who care for children with neurogenic bowel will be seeing more related complications including leakage, pain and granulation tissue [6]. Given that most ACE-Malone catheterizable channels have been performed open (>85%) [9], any minimally invasive option to convert these cecostomy buttons to a catheterizable channel could prove useful. The question of whether to perform a cecostomy conversion to a catheterizable channel by open, laparoscopic or robot-assisted laparoscopic means warrants discussion as each approach has distinct advantages and disadvantages [10], [11], [12]. The exact procedure described in this article likely would not be done in an open fashion. First in order to bring the right colon into any incision it would have to be mobilized free of the abdominal wall necessitating repair of the original cecostomy site. Second, the consistent tenting of the right colon by pneumoperitoneum would be more difficult to achieve in an open fashion. Finally, to put a patient through an open surgical procedure it is likely that most surgeons in an appendix-less patient would create an enteral conduit (a cecal flap or Monti) [13] and refashion a new, hidden mucosa-epithelial lined stoma. Although primary ACE-Malone creation with imbricated appendix has retrospectively been shown to be roughly equivalent in terms of procedure time (118min lap vs. 121min open, p=0.5) [12] given the complexity of suturing in a re-do Monti or cecal flap ACE, it is likely that open surgery would have a shorter procedural time than laparoscopy and a resultant lower operating room cost. The open surgery procedural time and cost advantage is counterbalanced by increased hospital length of stay, increased analgesia requirements, longer return to bowel function [12] and negative patient/family perception of surgical scars [14] as compared to laparoscopy. The decision by the authors to perform the procedure with robot-assistance as opposed to pure laparoscopy is based on two main factors. The first is the complexity of the suturing inherent to the procedure involving two-layered closure of the cecal flap with a third layer cecal wrap. Multiple authors have shown that both laparoscopic novices and experts alike benefit from the extra degrees of freedom afforded by the robotic platform [15], [16], and we feel this is definitely apparent with this procedure. The second is that although the procedure is triangulated and transperitoneal, there is a limited workspace created by the presence of the Mitrofanoff appendico-vesicostomy and its mesentery at the umbilicus, and widespread abdominal adhesions (often due to prior surgery and ventriculoperitoneal shunt). The robot facilitates laparoscopic intracorporeal suturing in a tight window with less instrument travel to perform both suturing and knot-tying. Other minor factors favoring the robotic approach include the quality of the optics, the visual magnification, and surgeon ergonomics. With the robot available at our institution, a general axiom is if the time spent docking and undocking the robot can be made up during complex suturing, a case can be made to use the robot on behalf of the patient over pure laparoscopy (capital cost of the robot and disposables notwithstanding). The authors acknowledge that an advanced laparoscopist could potentially perform this procedure without robot-assistance in a reasonable time with significant cost savings, smaller trocars (5mm vs. 8mm) and equivalent success.