LAPAROSCOPIC APPENDICOVESICOSTOMY (MITROFANOFF PROCEDURE) IN A CHILD USING THE DA VINCI ROBOTIC SYSTEM

Abstract

The Mitrofanoff principle was originally described as a method to provide an alternative means to access the bladder.1 It creates a conduit to the bladder through which patients with a sensitive, absent or traumatized urethra can perform clean intermittent catheterization (CIC) easily. To our knowledge we report the first case of an appendicovesicostomy performed entirely laparoscopically. CASE REPORT A 7-year-old boy with a history of posterior urethral valves and resultant valve bladder syndrome was referred with persistent high post-void residuals and recurrent urinary tract infections. He had previously undergone right heminephroureterectomy as well as left ureteral reimplantation and ureteral cystoplasty. The patient had an extremely sensitive urethra, which made CIC nearly impossible. After a discussion of the treatment options with the family laparoscopic appendicovesicostomy was elected. A 4-port transperitoneal approach was used (fig. 1). A 12 mm laparoscopic camera port was placed through the umbilicus and 2, 10 mm robotic laparoscopic ports were placed in the left lower quadrant and right midaxillary line at the level of the umbilicus. A fourth port was placed in the left midaxillary line, also at the level of the umbilicus. We began by mobilizing the appendix and right hemicolon up to the hepatic flexure. The mesentery of the appendix was identified and mobilized to obtain adequate length. The appendix was divided at its base using a gastrointestinal anastomosis stapler. The bladder was filled with saline an da5c mvertical seromuscular incision was made in the right posterior wall of the bladder down to the mucosa. After incision of the mucosa the appendix was anastomosed to the bladder using 4-zero chromic interrupted sutures using the da Vinci robotic system. The seromuscular layer of the bladder was closed using interrupted 4-zero polyglactin sutures, creating a tunnel for the appendix. The appendix was then brought up to the umbilicus and a catheterizable stoma was created. Smooth catheterization through the appendix with full pneumoperitoneum and with the pneumoperitoneum released was performed (fig. 2). A 16Fr suprapubic catheter was inserted into the bladder and an 8Fr stenting catheter was left through the appendix. Overall operative time was 6 hours and operative time for the anastomosis was 25 minutes. Estimated blood loss was 10 cc. There were no intraoperative or postoperative complications. The patient was started on a clear liquid diet the following day and did not require narcotic analgesia after postoperative day 1. He was discharged on postoperative day 4 and returned to normal activity at 10 days. He currently performs CIC every 6 hours without difficulty and is dry between catheterizations. The patient has been followed for 10 months and has not had to undergo stomal revision. DISCUSSION