Simultaneous Robot-Assisted Laparoscopic Continent Catheterizable Channels: The Split Appendix Technique

Abstract

Introduction: Mitrofanoff appendicovesicostomy (MAV) and Malone antegrade continent enema (MACE) have traditionally been performed using an open surgical approach for children with dual bladder and bowel dysfunction secondary to neurological impairment.1,2 Few reports exist in the literature in which laparoscopic or robot-assisted laparoscopic (RAL) approaches have been used for these procedures.3,4 We present a 4:59 video demonstrating the split appendix technique for the simultaneous creation of both MAV and MACE using an RAL approach. Methods: Three patients (mean age 10.6, range 7–14) with myelomeningocele have undergone the split appendix technique for RAL MAV and RAL MACE at our institution. Preoperative work-up included an evaluation of renal function, as well as a detailed analysis of bladder and sphincter function using videourodynamics. In addition, work-up included an assessment of constipation using the Bristol Stool Scale. Patients were brought to the hospital on the day of their surgery. No bowel preparation was used before the procedure. With the assistance of a nurse practitioner, detailed counseling was provided to patients and families before the procedure, including instruction on use of catheterizable channels. Results and Conclusions: Two patients underwent concurrent RAL ileocystoplasty and bladder neck closure; the third underwent concurrent placement of a transvaginal sling. There were no intraoperative or postoperative complications. All patients were discharged home on a mean postoperative day 5 (range 3–8). All patients catheterize the appendicovesicostomy every 3 hours, and use the MACE every 1–2 days. Patients leave the appendicovesicostomy on free drainage overnight. Continence of the appendicovesicostomy and MACE are excellent at 1 year in two patients who received concurrent ileocystoplasty. The third patient leaked from the appendicovesicostomy after 15 months and was found to have a reduced bladder capacity and increased pressures, requiring ileocystoplasty. There have been no stomal complications. In conclusion, simultaneous RAL MAV and RAL MACE performed using the split appendix technique can be an appropriate treatment for bladder dysfunction and constipation, provided that the appendix is a minimum of 7 cm in length (4–5 cm for the MAV and 2–3 cm for the MACE). If there is inadequate length of appendix to form the MACE, the cecum may be mobilized to obtain additional length. Because of the thick muscle and ample vascularity of the appendix, we believe that it is the preferred material over colonic flaps for antegrade continence enemas, with lower risk of long-term strictures and revisions.5 The authors report no conflicts of interest and have nothing to disclose. Runtime of video: 4 mins 59 secs