Laparoscopic cecostomy tube placement in an Indiana pouch

Abstract

A cecostomy tube is normally placed in an Indiana pouch for drainage and irrigation in the postoperative period. A clinical dilemma occurs when the cecostomy tube fails or is dislodged in the early postoperative period. We present the laparoscopic replacement of a cecostomy tube in the immediate postoperative period. Can Urol Assoc J 2010;4(1):E7-E8 IntroductionDuring the creation of a continent cutaneous reservoir, such as the Indiana pouch, a small calibre catheter is usually placed through the imbricated efferent limb of ileum for 48 hours. 1 It is normally removed in the early postoperative period. A large calibre mallencott drainage tube is usually placed in the reservoir (normally through the cecum) at the time of surgery and used for irrigation and maximal drainage to facilitate reservoir healing. This large catheter is usually removed as an outpatient procedure 2 to 3 weeks postoperatively. Prior to removal, it is clamped and patients are instructed on the catheterization of the efferent limb. Thus, early maintenance of the drainage is vitally important. In the event of a nonfunctioning or dislodged catheter in the early postoperative period, replacement is prudent. In the pediatric population with spinal dysraphism, laparoscopic cecostomy tube placement for anterograde enemas has been described. 2,3 Multiple urinary diversion procedures, such as the Studer pouch, 4 rectosigmoid pouch 5 and ileal conduit, 6 have been performed with minimally invasive intracorporeal techniques, although catheterizable cutaneous reservoirs are normally completed extracorporeally with a small laparotomy. 7 Regardless of the technique of the initial operation, proactive management options include replacement by repeat laparotomy, percutaneous placement, or, as described in this case report, laparoscopic cecostomy tube placement. Case reportA 46-year-old paraplegic man with a neurogenic bladder resulting from a thoracic vertebral fracture after a motorcycle accident presents with a long history of incontinence, poorly compliant bladder and bilateral vesico-ureteral reflux. He was on high-dose anticholinergic therapy and compliant with intermittent catheterization, but still only had a functional bladder capacity of 50 mL. He later developed a severe sacral decubitus, which ultimately extended to the urethra. After counselling, he elected to undergo simple cystectomy and Indiana pouch construction.The cystectomy and Indiana pouch were completed in an open surgical fashion without complications. Twentyfour hours after the operation, the patient was being transferred to a wheelchair and the cecostomy tube was inadvertently dislodged. The patient was asymptomatic, but saline flush through the efferent limb of the Indiana pouch was not adequate for mucous removal. Having a fresh pouch with only 12 French drainage through the continent limb was a concern for the operative team because of the inherent risk of obstruction due to mucous clot. Replacement of an adequate drainage tube would help prevent sequela from mucous obstr...