Laparoscopic Assisted Reconstructive Surgery:: A 7-Year Experience

Abstract

Laparoscopic assisted surgery results in an improved cosmetic appearance by allowing complex reconstruction without a midline upper abdominal incision. We report technique and outcomes in patients undergoing laparoscopic assisted reconstruction during a 7-year period. A total of 31 consecutive patients with a mean age of 14 years (range 1 to 36) underwent laparoscopic assisted reconstructive surgery through a lower midline or Pfannenstiel incision by a single surgeon (SGD) between June 1995 and July 2002. Diagnoses included myelomeningocele (17), sacral agenesis (2), posterior urethral valves (2), classic bladder exstrophy (5), complicated ectopic ureter with ureterocele (1) and quadriplegia due to trauma (4). A total of 29 patients had 39 continent stomas (antegrade continence enema [ACE] or Mitrofanoff) created as part of the reconstruction. One case was converted to an open procedure due to dense adhesions and was excluded from the study. Continent stoma construction included Mitrofanoff stomas created from appendix (17), ileum (3), sigmoid (5) and bladder (1), and ACE stomas from appendix (12) and ileum (1). Ten patients underwent concurrent Mitrofanoff and ACE procedures. Laparoscopy was used for lysis of adhesions, mobilization of colon and/or harvesting the appendix, nephrectomy in preparation for ureteral augmentation, division of pedicle for gastrocystoplasty takedown and harvesting of omentum for interposition. Bladder augmentation (15), bladder neck reconstruction (7), fascial sling (3), ureteral reimplants (1), revision of epispadias (2) and/or redo orchiopexy (1) were concurrently performed in 19 patients. Data were obtained through chart review and personal communication. Median hospital stay was 6 days (range 2 to 20). Mean followup was 32 months (range 3 to 57). Revisions were required in 3 stomas (7.7%) at a mean of 19 months (range 8 to 36) postoperatively. Minor procedures were required in 10 stomas (25.6%) consisting of indwelling catheterization, dilation, collagen injection and cystoscopy. Of the 39 stomas 37 (94.9%) were continent of urine and/or stool, and easily catheterizable at last followup. Adequate capacity and compliance were maintained in all augmented bladders. No patient experienced delayed small bowel obstruction or other sequela of abdominal adhesions. At almost 3 years of mean followup laparoscopic assisted reconstructive surgery offers functional outcomes at least equivalent to conventional open surgery in complicated cases with excellent cosmesis. Laparoscopic assisted surgery remains our approach of choice for children and adults who require lower urinary tract reconstruction with a continent catheterizable stoma.