Malone appendicostomy in a Patient with Prior Abdominal Surgery via a prior abdominal incision

Malonaendicostomy in a patient with prior abdominal surgery. A mylo appendicostomy provides an anti-grade route for continent enemas as part of a bowel management plan. Laparoscopy is an ideal approach, but requires an infra umbilical fascial incision to do the extracorporeal cecal lication. Prolapse of the appendiceal tissue, umbilical hernia, and stommal stenosis are described complications. We propose a modification that spares the midline fascia, offers an opportunity to perform a scar revision, and provides abdominal access for the application. This technique is intended for patients with a history of abdominal surgery such as a colostomy who need a mechanical regimen to empty the colon, particularly in patients with anorectal malformations, Hirsprung disease, medically refractory constipation, or spinal disorders. We present the case of a 4 year old boy with an anorectal malformation and an associated tethered cord who had a divided sigmoid colostomy at birth. Posterior sagittal anorectoplasty for a recoprostatic fistula at age 4 months, followed by a colostomy closure at age 6 months were performed, leaving him with a left lower quadrant oblique scar as pictured. He suffered for years of constipation and inability to potty train, and he was referred to our center for evaluation. A redo PA for an anal mislocation and a Malo appendicostomy to provide antegrade access were performed. The Malone will keep him clean after the redo and offer the opportunity to have him train by holding in the flush to help him develop bowel control with his now improved interectal anatomy. An elliptical incision is marked around the previous abdominal scar to improve the cosmetic result when closed. The incision is deepened and flaps are created above the fascia. The abdomen is entered safely and a small transverse fascial incision is made. The abdominal incision is adequate to reach the pelvis and right lower quadrants in most cases. If this is not the case, laparoscopy could be used to mobilize the right colon. A pair of atraumatic ring forceps grafts the cecum and delivers it through the incision. Attachments to the pelvis or retroperitoneum can be taken down. A stay suture using 40 vicryl is placed through the appendix tip to help with manipulation. Filmy attachments to the appendix are divided to straighten it and expose the vasculature of its mesentery. A window is created in the meso appendix close to the base. The distal appendix is excised, leaving approximately 5 centimeters of appendix for the placation and to reach the umbilicus without tension. A neo Malone can be created at this step if no appendix is available or if a Metrofanoff is being done at the same time. The cecum is brought through the window to set up the placation, avoiding the terminal ileum or creating redundancy. The lication acts as a valve mechanism to prevent reflux through them alone. 30 silk sutures take serum muscular bites of the cecum, appendiceal wall, and cecum on the other side. A 10 French coup de tip Foley catheter is threaded into the lumen to act as a bougie. The catheter tips should be confirmed to enter the right colon and not the terminal ileum. Additional 30 silk sutures are placed for the lication. A silk stay suture is placed at the deepest point of the umbilical recess, and the umbilicus is turned inside out. A small circular incision is made. A mosquito clamp is used to enter the abdomen through the umbilical ring. This technique spares the infra umbilical fascia. The clamp grasps the stay suture on the appendix tip, and it is delivered through the umbilical incision. Phoo viral sutures are used to take full thickness bites of the appendix to the skin circumferentially. The previous 10 French coude catheter is reintroduced into the right colon. The Foley balloon is inflated and verified to be in the cecum and not the terminal ileum. A 3-oprole is used to secure the catheter to the skin. The catheter remains for the first month postoperatively until the patient transitions to an indwelling device or intermittent catheterizations. The abdomen is closed in layers. 102 patients underwent Malonaendicostomy at our institution from 2020 to 2021. 52 patients underwent the procedure in this described method by a prior abdominal incision. 56% had anorectal malformation, 23% had Hirschprung disease, 12% had functional constipation, and 10% had a spinal disorder. 48 patients had their malone orifice placed in the umbilicus, and in 4 the right lower quadrant was used, all with a circular pendicoplasty. There were no intraoperative complications. There were 2 prolapses of them alone with umbilical hernia reported, but no significant difference compared to a group of Malone procedures done laparoscopically. There were no cases of stommal stenosis reported in either group.