Intermediate-Term Outcome of the Simplified Laparoscopic Antegrade Continence Enema Procedure: Less is Better

Purpose: The Malone antegrade continence enema procedure revolutionized the surgical management of fecal incontinence. Open and laparoscopic antegrade continence enemas are often performed with cecoplication and mesenteric manipulation. Since our initial laparoscopic antegrade continence enema description, we have simplified our technique. We present our series of laparoscopic antegrade continence enema procedures, discuss technique and outcomes, and review the literature. Materials and Methods: We retrospectively reviewed children who underwent laparoscopic antegrade continence enema between 2001 and 2007. Outcome measures included operative time, length of stay, stomal complications and resolution of incontinence or constipation. Using an umbilical port and 1 to 2 additional ports, the appendix was mobilized to allow transposition to the umbilicus. No cecoplication was performed. The appendix was not straightened unless catheterization was difficult. Results: A total of 22 patients (mean age 7.8 years) underwent laparoscopic antegrade continence enema. Of the patients 21 were discharged home on postoperative day 1. Mean operative time was 65 minutes (range 30 to 116). In the last 10 patients only 1 working port was used. No perioperative complications were encountered. Mean followup was 24 months (range 1 to 68). Constipation and fecal incontinence resolved in all cases. No patient experienced stomal complications. One obese patient with kyphosis could not pass the catheter beyond the mid appendix at 1 month postoperatively. She had the same problem 1 month following open antegrade continence enema with cecoplication. Conclusions: Laparoscopic antegrade continence enema is an effective means of treating intractable fecal incontinence and constipation. Our technique of using in situ appendix without cecoplication requires minimal mobilization and manipulation of the blood supply. Secondary ischemia, adhesions and scar formation are reduced, alleviating the most common complication, stomal stenosis. Our results show that cecoplication is not necessary to maintain stomal continence.