Pediatric Surgery International https://doi.org/10.1007/s00383-018-4289-2
ORIGINAL ARTICLE
Laparoscopic-assisted divided colostomy for anorectal malformation case series: a description of technique, clinical outcomes and a review of the literature Saurabh Saxena1,2 · Mitchell Gibbons2 · Kaveer Chatoorgoon1,2 · Gustavo A. Villalona1,2 Accepted: 23 May 2018 © Springer-Verlag GmbH Germany, part of Springer Nature 2018
Abstract Objective To present a case series of pediatric patients who underwent a laparoscopic-assisted divided colostomy for anorectal malformations, describe our technique, and provide a review of the literature on laparoscopic-assisted colostomy in pediatric patients. Methods We performed a retrospective review of six patients born with anorectal malformations, who received a laparoscopic-assisted colostomy from 2012 to 2016 at Cardinal Glennon Children’s Medical Center. Results The average operating time was 74.5 min. Laparoscopic colostomy types included divided (n = 5) and end colostomy with Hartmann’s (n = 1). Location of the colostomy was selected just distal to the descending colon (n = 5) or at the sigmoid flexure (n = 1). Feeds and stoma production was achieved within 24 h from surgery in most patients. There were no major complications except one patient having a mucosal fistula prolapse that was easily reduced. Conclusions Laparoscopic-assisted colostomy in the management of anorectal malformations is a safe and effective technique. It offers similar advantages of the open technique, with the added benefits of avoiding wound-related complications and improved cosmetic results. Keywords Laparoscopic-assisted divided colostomy · Anorectal malformation · Pediatric
Introduction Congenital anorectal malformations are a challenging group of defects that occurs 1 in every 5000 births in the US. Lower defects can be treated with primary repairs with or without a colostomy, but in higher defects and in patients with associated comorbidities, a temporary colostomy is often the first step. The goal of the colostomy is to divert * Saurabh Saxena
[email protected] Mitchell Gibbons
[email protected] Kaveer Chatoorgoon
[email protected] Gustavo A. Villalona
[email protected] 1
Department of Pediatric Surgery, Cardinal Glennon Children’s Medical Center, St. Louis, USA
Saint Louis University School of Medicine, St. Louis, USA
2
the fecal stream to prevent urinary tract infections, as well as to allow for growth of the child until a pull through can be performed. Open laparotomy is a common method for colostomy creation, but complications as high as 70% have been reported. These complications include wound dehiscence, stoma prolapse, intestinal obstruction, and stomal mislocation [1–3]. Multiple techniques have been described for patients with anorectal malformations including transverse colostomy, Hartmann’s colostomy, and loop colostomies. All of them with their own set of complications. Pena et al. [2] showed his results from a multi-institution review of complications, where he described his technique for an open divided colostomy at the descending/sigmoid colonic junction with a small and flat distal stomas. He demonstrated that his technique decreased common complications such as stoma mislocation, short distal mucous fistula, inverted stoma, prolapse, retraction and distal fecal impaction [2]. Although not reported in their study, the most common complication we have seen with this technique is woundrelated complications (infection and/or wound dehiscence),
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complicating ostomy appliance use and further aggravating skin breakdown (Fig. 1). This being one of the main reasons we started the use of a laparoscopic technique. Laparoscopic-assisted colostomy (LAC) in adults has been associated with faster return of bowel function, shorter hospital stay, less pain, and faster oral intake [4]. For patients with anorectal malformations, the use of laparoscopy also provides the advantage of being able to visualize the genitourinary system during colostomy creation, as well as avoiding common complications as described by Pena et al. To date, there have been four case series reporting LAC in newborns [5–8]. These cases series included patients with Hirschsprung’s disease and anorectal malformation, with a wide variety of techniques including location and number of ports, location of stomas and loop vs divided colostomies. A systematic review of the literature for all English language publications was performed using Pubmed, Google scholar and the Cochrane Library. Publications on various laparoscopic techniques and outcomes for management of anorectal malformations were reviewed. Our hope with this study is to provide a comprehensive review of complications seen with laparoscopic approach and unlike previous studies, try to provide a detailed description of laparoscopic assisted divided colostomy and takedown in patients with anorectal malformation with intra and post-operative images.
Method/procedure Retrospective review of patients born with anorectal malformations was performed between 2012 and 2016 at Cardinal Glennon Children’s Medical Center. 6 patients were
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identified that underwent laparoscopic assisted colostomy. Decision to do this procedure laparoscopically was upon surgeon’s preference with seven patients undergoing open colostomy during the same time period. At our center, laparoscopic technique has typically been used for patients with rectourethral, rectoprostatic and rectobladder fistulas. Once patient is anesthetized and surgically prepped, a periumbilical incision is made and a 3 mm trocar is placed into the peritoneal cavity. We prefer placing the port on the right lateral aspect of the umbilicus to improve visualization and to avoid ligating or injuring the umbilical vessels. Before insufflation is initiated, we confirm the intraabdominal position with the laparoscope. Abdomen is then insufflated using low flow at 4–5 l/min with pressure set at 8–10 mmHg. Using this technique we did not find any issues ventilating patients. A diagnostic laparoscopy is performed and we first identify the anatomy of the colon to choose our colostomy site. The descending/sigmoid junction is chosen as the site. We then evaluate for anomalies in the genitourinary system and the reproductive system in females. Once we have confirmed the anatomy we place a 3 or 5 mm trocar in the left lower quadrant at the proposed colostomy site (Fig. 2a). The site selected for colostomy is grasped and pulled out through the incision which is enlarged to about 1 cm. The colon is divided using an endoGIA stapler to minimize spillage. The distal staple line corner is opened using electrocautery and a 20 French red rubber catheter is inserted distally to irrigate and evacuate the distal colon (Fig. 2b). For this vital part of the procedure, we made more openings on the red rubber catheter, using a 60 ml syringe we irrigate warm normal saline and we aspirate with the same syringe. Finally, we pass a pool sucker to further aspirate the saline
Fig. 1 Open technique wound related complications. Arrows point at wound dehiscence and skin breakdown
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Fig. 2 Intraoperative findings: schematic of periumbilical port site and colostomy site at the left and sigmoid colon junction (a). Distal colon irrigation (b). Proximal colon and mucous fistula seen after
irrigation (c). Laparoscopic view of proximal colon and mucous fistula confirming correct anatomy (d)
and meconium. Using laparoscopy we confirm that the distal colon is decompressed (Fig. 2c) and we choose the site for the mucous fistula while avoiding the umbilical vessels and the bladder. We then place traction sutures in a figure of eight fashion with 4-0 silk at the mucous fistula end. Using the mucous fistula incision we pass either a 3 mm grasper or a tonsil clamp into the abdomen where these traction sutures are grabbed and pulled through to create the mucous fistula. The incision is enlarged to about 5 mm to accommodate the bowel. Again, using laparoscopy the colonic loops are again visualized using the scope to confirm the position of proximal and distal loops, and that there is no twisting of the mesentery (Fig. 2d). The peritoneal cavity is desufflated and scope removed. We place several tacking sutures to the fascia and then the proximal colonic segment staple line is removed with electrocautery and a standard end colostomy is fashioned in a Brooke’s fashion. The traction sutures of the
distal colonic end are removed and the prior opening is used to create the mucous fistula by tacking it to the fascia. The umbilical incision is closed in layers and the skin is covered with skin glue. Ostomy and mucous fistula are dressed with vaseline gauze.
Case 1 A term male infant who was prenatally diagnosed with right renal agenesis and single umbilical artery presented soon after birth for evaluation of anorectal malformation and a bifid scrotum. Physical exam revealed an absent anus with no perineal fistula, normal genitalia with a bifid scrotum, and no remaining abnormalities. X-ray of the chest and abdomen revealed T4 vertebral abnormality and distal sacral and coccygeal agenesis. On admission a replogle was placed, he
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was made NPO and scheduled for a laparoscopic divided colostomy on day of life two. The procedure lasted 75 min. Figure 3 represents the divided colostomy at the end of the procedure and at 2 months after creation. During the operation a distended sigmoid colon was identified, which was successfully decompressed after irrigation. The stoma was productive on postoperative day (POD) 0, and the patient was feeding by POD 1. Voiding cystourethrogram during his urologic workup had revealed a clear rectoprostatic urethral fistula. This study eliminated the need for a distal colostogram. He underwent a successful rigid cystoscopy and posterior sagittal anorectoplasty (PSARP) at 3 months of age and the colostomy was reversed 2 months later (Fig. 4). There were no complications related to the stoma or after its reversal. Figure 5 demonstrates the cosmetic result of ostomy takedown at the end of the operation and several months later.
Case 2 A 6 weeks old female born at term with a rectovestibular fistula and small PFO. Two weeks later the mother brought the patient to the emergency room for oral thrush and upon physical exam an anorectal malformation was noted. She was initially treated with dilations of the rectovestibular fistula and was discharged home with a plan for outpatient single stage repair. Physical exam, X-rays and renal/spinal canal ultrasounds were unremarkable. The patient underwent a single stage PSARP at 3 months of age which was complicated by wound infection/dehiscence on postoperative day 3. At this time an exam under anesthesia (EUA) with irrigation
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and suture repair of the dehiscence was performed. On postoperative day 6 the patient was taken to the operating room for a laparoscopic assisted end colostomy and anoplasty revision due to further dehiscence of the wound. During the operation no anatomic defects were noted. There was no distal mucosal stoma site created in this operation because the lower colonic, rectal, and GU anatomy were already known and the end colostomy was a surgeon preference. Although a mucous fistula can be created for this cases as well. The stoma was productive and the patient was having oral formula intake by POD 1. After 13 days of hospitalization the patient was discharged. The colostomy was reversed after 6 months. There were no complications with the stoma site after its reversal.
Case 3 A preterm male born at 36 weeks with mild respiratory distress syndrome was transferred to our hospital for findings of hypospadias, bifid scrotum, bilateral dysplastic kidneys and anorectal malformation. Physical exam was remarkable for anorectal malformation with flat bottom and no evidence of fistula (Fig. 6a). X-rays revealed abnormal sacrum and spinal ultrasound showed a conus medullaris at the level of L4. Patient was placed on NPO with nasogastric tube and received a laparoscopic divided colostomy on day of life 2. The procedure lasted 78 min. During laparoscopy we noted that his sigmoid was short and a rectobladder fistula was identified, which was later confirmed by distal colostogram. Given the shortened sigmoid we decided to create our colostomy in the left
Fig. 3 Divided colostomy after surgery (a) and at 2 months after surgery (b)
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Fig. 4 Intraoperative technique for colostomy takedown
Fig. 5 Surgical site after surgery (a) and several months after (b)
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Fig. 6 Anorectal malformation and flat bottom (a). Port side to the right of the umbilicus and final position of stomas (b). Prepping prior to ostomy takedown (c). Scars after surgery (d)
colon to allow for enough length for future pull through. During the procedure the umbilical vein catheter was preserved by placing 3 mm port right lateral umbilical incision (Fig. 6b). He was feeding and having ostomy output by POD 1. The patient’s hospital stay was complicated by urinary infection and inguinal/umbilical hernia repair. The patient was discharged 4 months after initial presentation. There were no colostomy-related complications. At 10 months of age, he underwent laparoscopic-assisted ligation of bladder neck fistula, laparoscopic-assisted posterior sagittal anorectoplasty and laparoscopic gastrostomy tube placement. The sigmoid/rectum were further mobilized during this procedure to achieve length for the pullthrough despite we had made a more proximal colostomy. There were no issues with the colostomy site after take down (Fig. 6c, d).
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Case 4 A preterm male born at 34 weeks with absent right radial bone, cleft palate, micrognathia, webbed neck, was seen for surgical evaluation after a replogle was unable to be passed into the stomach with associated double bubble on X-ray immediately after birth. He was 1.8 kg and on physical exam he was noted to have a cleft palate, scaphoid abdomen and found to have an anorectal malformation without fistula. An ECHO revealed a small perimembranous VSD, small ostium secundum ASD, and moderate PDA. Additional imaging confirmed esophageal atresia with associated tracheoesophageal fistula with the replogle coiled in upper esophagus, duodenal atresia with double bubble sign, sacral spinal dysraphism, small periventricular calcifications and a left echogenic kidney
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with associated left calyx and ureter dilation. Spine MRI showed tethered cord which is pending repair. With his triad of esophageal atresia with tracheoesophageal fistula, duodenal atresia and anorectal malformation the decision was made to take him to the operating room for rigid bronchoscopy, gastric tube placement, tracheoesophageal fistula repair, and broviac placement on day of life 1. At DOL 9 when patient had sufficiently recovered from initial procedure he was taken for laparoscopic divided colostomy followed by open duodenal atresia repair (Fig. 7). The stoma was productive on POD 5, contrast study showed no leak and the patient began enteral feeds POD 9. The hospital stay was further complicated by inability to wean off respiratory assist due to bronchopulmonary dysplasia, and coarctation of the aorta. He was discharged from the NICU 4 months after admission on 100% FiO2 via nasal cannula. The colostomy is ongoing, PSARP will be performed after cleft palate and tethered cord repair. Two and a half months postoperatively there was a mucosal fistula prolapse that was easily reduced. There were no other stoma complications.
Case 5 A term newborn male with bilateral hydroceles presented on day of life 0 for evaluation of anorectal malformation. Physical exam was notable for bilateral hydroceles, and anorectal malformation without evidence of fistula. Imaging revealed small PFO and small PDA, and the rest was unremarkable. On day of life 1 the patient was taken for a laparoscopic divided colostomy. The procedure lasted 65 min and had no difficulties intraoperatively. The patient was feeding and
having stoma output by POD 1. During his admission he had adequate weight gain and was discharged on POD 3. There were no complications with the ostomy sites. Prior to colostomy take down the distal colostogram revealed a fistula between the rectum and urinary tract, but due to dilute contrast the radiologist was unable to determine the exact location. He underwent a diagnostic laparoscopy and PSARP at 3 months of age which confirmed a recto-prostatic fistula. The colostomy was reversed at 7 months of age with no complications.
Case 6 A preterm male born at 34 weeks presented on day of life 0 for evaluation of an anorectal malformation. Physical exam revealed anorectal malformation with no associated fistula with the remainder of the exam being unremarkable. However, on day of life 2 stool was noted to be coming out of the urethra which was later confirmed to be a rectourethral fistula by voiding cystourethrogram (VCUG). Imaging revealed dysmorphic coccyx, tethered cord with conus ending at L4 on MRI, and a small PDA on cardiac echo. He was taken for a laparoscopic divided colostomy with Foley placement on day of life 2. The operation lasted 80 min and there were no difficulties intraoperatively. The patient was passing meconium through his ostomy by POD 1, stable on room air by POD 2, and feeding by POD 4. The Foley was removed by POD 4 after VCUG. The postoperative course was complicated by blood cultures growing gram positive bacillus secondary to a neurogenic bladder causing urinary stasis and urinary infections which were treated with vancomycin, cefotaxime, and foley decompressions performed
Fig. 7 Decompressed sigmoid and rectum due to duodenal atresia (a). Final position of divided colostomy (b)
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Complications
Type of ARM
Rectoprostatic urethral fistula None
Colostomy type Divided colostomy
ARM without fistula, Bifid scrotum
Physical exam End colostomy with Hartmann’s ARM with rectovestibular fistula None
ARM with rectovestibular fistula
2dM 4moF Right renal agenesis, bifid PFO scrotum, subependymal Hemorrhages, T4 vertebral abnormality, distal sacral and coccyx agenesis, PFO, PDA
Age/sex Comorbidities
2
1
Case
4
ARM with recto-bladder fistula None
Mucosal fistula prolapse
ARM
2dM 8dM Hypospadias, bifid scrotum Absent right radial bone, cleft palate, microgBilateral dysplastic kidnathia, webbed neck, neys, L4 conus medulVSD, ASD, PDA, laris esophageal atresia with tracheoesophageal fistula, duodenal atresia, sacral spinal dysraphism, small, periventricular calcifications, tethered cord ARM with flat bottom, ARM without fistula, nonbifid scrotum distended abdomen, Cleft palate Divided colostomy Divided colostomy
3
Table 1 Summary of our case series of our patients undergoing laparoscopic colostomies
ARM with recto-prostatic fistula None
ARM without fistula Bilateral hydroceles and ARM without evidence of fistula Divided colostomy
ARM with rectourethral fistula None
Divided colostomy
2dM Dysmorphic coccyx, tethered cord with conus ending at L4, PDA
6
1dM Bilateral hydroceles, PFO, PDA
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Conversion to open due to anesthesia problems, late stricture, misinterpretation of two ends of bowel, minor postoperative infection
None
Urinary infection secondary to vesicoureteral reflux
None
Unspecified ARMs
Complications
Unspecified ARMs
High and intermediate ARMs
Type of ARM Hirschsprung’s disease ARM
Loop defunctioning colos- Loop and divided sigmoid Divided descending colostomy colostomy tomy, defunctioning colostomy
6 Not specified
Gine et al. 2016 [8]
Loop, divided, double and double barrel left transverse colostomy
11 Cloaca, severe cardiac malformation, Remainder not specified
Arnjornsson [7]
Colostomy type
De Carli et al. [5] 3 Enterocolitis, large bowel obstruction
Liem and Quynh [6]
Number of patients 39 Comorbidities Not specified
Report
Table 2 Review of the literature of patients undergoing open vs laparoscopic colostomies
6 Cardiac, renal, spinal cord, vertebral malformations, esophageal atresia with TEF, duodenal atresia Divided classic descending and sigmoid colostomy End colostomy with Hartmann’s Imperforate anus with and without genitourinary fistulas Mucosal fistula prolapse, urosepsis, UTI, bladder injury during takedown
5 our series
2 wound infections, anastomotic dehiscence, small bowel obstruction all occurring after the colostomy was closed
Unspecified ARMs
Divided descending colostomy
50 Not specified
Pena et al. [2]
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through the mucosal fistula and urethra, we believe this was most likely due to patient anatomy and disease process. The patient was discharged 25 days after admission. No distal colostogram was performed because the VCUG had shown a clear rectoprostatic fistula. He underwent a PSARP repair at 5 months of age and his colostomy was takedown at 8 months of age. No other complications were noted with the colostomy.
Discussion We present six patients with anorectal malformations that received a laparoscopic-assisted colostomy. Colostomy creation must be done with special attention to the location, abdominal anatomy, tension on the bowel, and stoma site to prevent common complications such as wound dehiscence, stoma prolapse, intestinal obstruction, and stomal mislocation [1–3]. Of the patients, five of these were male and one female (Table 1). The average operating time was 74.5 min. All operations were performed laparoscopically with the colostomy just distal to the descending colon, except for one done in the left colon due to rectobladder fistula with short sigmoid. Laparoscopic divided colostomies were created in five patients, however, one patient received an end colostomy with Hartmann’s in girl after a primary PSARP was complicated with wound dehiscence. The mean time for stoma productivity and enteral feeding initiation was less than 48 h. There was one incidence of mucosal fistula prolapse which was reduced at the bedside with no further complications. It is unclear why this happened. Standard technique of suturing mucous fistula to fascia was used in all patient with mucous fistula. One patient developed urosepsis with positive blood cultures secondary to neurogenic bladder and urinary stasis which allowed retrograde flow into rectosigmoid pouch leading to distended rectosigmoid pouch. This was treated effectively with antibiotics and decompressions through the mucous fistula and urethra. We believe this was not a complication of colostomy and was more related to patient anatomy. There were no stoma site infections or wound dehiscence. One patient still has his ostomy in place due to multiple abnormalities and pending cleft palate and tethered cord repair. The five remaining ostomies were in place for a mean of 8 months. In comparison to the open procedure, the laparoscopic colostomy technique has many of the same benefits with the addition of identifying genitourinary anatomy, avoiding wound-related complications, as well as a superior cosmetic result. Our experience is similar to previously reported descriptions using the laparoscopic approach, demonstrating to be a safe and effective tool for patients with anorectal
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malformations [2, 5–8]. Regardless of the laparoscopic technique used, it is imperative to follow the classic principles established by Pena et al. for divided colostomies in the proper anatomic location [2]. In Table 2 we show the most current review of the literature. We feel this is a safe technique since the complications reported had no major changes in patient care and some of them are related to patients own condition or anatomy. The main limitation of our study is that we are reviewing a small number of patients with the main goal to demonstrate the feasibility of the laparoscopic technique. We currently advocate the use this technique for patients with rectourethral, rectoprostatic and rectobladder fistulas that are not deemed too ill to undergo laparoscopic surgery.
Conclusion Laparoscopic-assisted colostomy in the management of anorectal malformations is a safe and effective technique. It offers similar advantages of the open technique, with the added benefits of avoiding wound-related complications and improved cosmetic results. Funding No funding was received for this study.
Compliance with ethical standards Conflict of interest Mr. Saurabh Saxena declares that he has no conflict of interest. Mr. Mitchell Gibbons declares he has no conflict of interest. Mr. Kaveer Chatoorgoon declares he has no conflict of interest. Mr. Gustavo A. Villalona declares he has no conflict of interest. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent Since this study was done as a retrospective review of preexisting clinical data with no individually identifiable information collected this study was approved as an exempt study by Saint Louis University Institutional Review Board and no informed consent was required for this study.
References 1. Patwardhan N, Kiely EM, Drake DP, Spitz L, Pierro A (2001) Colostomy for anorectal anomalies: high incidence of complications. J Pediatr Surg 36(5):795–798 2. Pena A, Migotto-Krieger M, Levitt MA (2006) Colostomy in anorectal malformations: a procedure with serious but preventable complications. J Pediatr Surg 41(4):748–756 (discussion 748–56) 3. Chandramouli B, Srinivasan K, Jagdish S, Ananthakrishnan N (2004) Morbidity and mortality of colostomy and its closure in children. J Pediatr Surg 39(4):596–599 4. Young CJ, Eyers AA, Solomon MJ (1998) Defunctioning of the anorectum. Dis Colon Rectum 41(2):190–194
Pediatric Surgery International 5. De Carli C, Bettolli M, Jackson C-C, Sweeney B, Rubin S (2008) Laparoscopic-assisted colostomy in children. J Laparoendosc Adv Surg Tech A 18(3):481–483 6. Liem NT, Quynh TA (2013) Single trocar laparoscopic-assisted colostomy in newborns. Pediatr Surg Int 29(6):651–653 7. Arnbjörnsson EA (2015) Two ports laparoscopy-assisted colostomy in neonates—a method described. MOJ Surg. https://doi. org/10.15406/mojs.2015.02.00011 (Internet)
8. Gine C, Santiago S, Lara A et al (2016) Two-port laparoscopic descending colostomy with separated stomas for anorectal malformations in newborns. Eur J Pediatr Surg 26(5):462–464
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