Laparoscopic Segmental Colectomy for Functional Constipation

We present the case of a 6-year-old girl with functional constipation refractory to medical management. Her evaluation included a rectal biopsy and anorectal manometry, both of which were normal, and colonic manometry. She was found to have a 40 centimeter segment of dismotile colon and colonic manometry. Her contrast enema demonstrated a grossly dilated distal colon. We have previously published our systematic approach to the management of children with severe functional constipation. Our patients' findings are consistent with those in Group D. In keeping with this, we initially created a Mlo appendeostomy, which improved her symptoms, but after several months she began to suffer from impactions despite multiple colonic irrigation regimens. A decision was made to resect the dismodal colon. Preoperative bowel preparation was used to ensure decompression of the distal colon at laparoscopy. Port placement for this operation is shown here. A 5 millimeter optical port is placed supraumbilically and to the left to avoid injury to the appendicostomy. Additional ports are placed under vision in the left upper quadrant and the right lower quadrant. The left colon is surveyed, demonstrating a grossly dilated redundant sigmoid colon which funnels into a more normal caliber rectum above the peritoneal reflection. Dissection begins at the pelvic brim using a vessel sealing device to create a mesenteric window. Dissection proceeds in a caudal direction, staying close to the bowel. The position of the ureters is also established to ensure they lie away from the dissection plane. The mesentery is divided as two separate leaflets closer to the rectum. Once normal caliber colon is encountered above the peritoneal reflection, the rectum is transected using an endoGIA stapler. Several staple fires may be needed depending on the degree of dilatation. Again, we check to ensure that the ureter has not been inadvertently caught in the staple line. Dissection then returns to the pelvic brim where the peritoneal attachments of the left colon are divided in a cephalad direction. Sufficient mobility of the normal caliber colon to reach the pelvis is noted, and in this case, taking down the splenic flexure was not required. Once this is completed, the staple dent of the colon to be resected is held with a ratcheted bowel grasper and brought through the right lower quadrant port, the incision for which is extended to approximately 2.5 centimeters. The grasper and colon are passed through a wound protector which is applied to the right lower quadrant port site. The redundant dismotile colon is transected, and the anvil component of an EEA circular stapler is placed into the lumen of the healthy colon and secured in place using a prolene purse string suture. The colon is then returned to the peritoneal cavity and a laparoscopic cap applied over the wound protector to allow reestablishment of pneumoperitoneum. The mobility of the colon to be anastomos to the rectum is again assessed. Its orientation is also examined to ensure that there is no twist on the colon as it passes into the pelvis. The colon should now lack redundancy and form a direct path into the pelvis. The rectum is calibrated using scisors that come with a circular stapling device. The circular stapler is passed into the rectum, and under vision, the EEA trocar is deployed adjacent to the rectal staple line until the orange tying area is seen. The anvil is grasped with a laparoscopic anvil grasper and engaged into the trochar until a characteristic snap is felt. The EEA device is then closed until appropriate tissue compression is attained. The stapler is then fired. The anvil trochar mechanism is disassembled to ensure two complete doughnuts of colonic tissue are present, indicating a satisisfactory anastomosis. The integrity of the anastomosis is then examined by filling the pelvis with saline and insufflating air into the rectum. No bubbling is seen. Excess irrigation fluid is evacuated. All laparoscopic instruments are removed, and closure proceeds. The patient was discharged on the 4th postoperative day following a resumption of bowel function and establishment of diet and appendecostomy flushes. Her flush regimen was dramatically improved after resection, and the plan is to attempt to transition her to oral laxatives. In summary, we present the case of a 6-year-old girl with medically refractory functional constipation who has segmentally abnormal colonic motility. With normal anorectal manometry in whom both Malone appendicostomy flushes and a laparoscopic segmental colonic resection were required to successfully manage her symptoms.