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Laparoscopic Segmental Colectomy for Functional Constipation
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What the experts said
Rectal biopsy and anorectal manometry were both normal in this patient with functional constipation.
Colonic manometry identified a 40 centimeter segment of dysmotile colon.
Contrast enema demonstrated a grossly dilated distal colon.
The authors have previously published a systematic approach to management of children with severe functional constipation, with patients classified into groups; this patient's findings were consistent with Group D.
Initial Malone appendicostomy improved symptoms, but after several months the patient began suffering from impactions despite multiple colonic irrigation regimens.
Preoperative bowel preparation was used to ensure decompression of the distal colon at laparoscopy.
A 5 millimeter optical port is placed supraumbilically and to the left to avoid injury to the appendicostomy.
The left colon demonstrated 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, proceeding in a caudal direction and staying close to the bowel.
The position of the ureters is established to ensure they lie away from the dissection plane.
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.
After stapling, verification is performed to ensure that the ureter has not been inadvertently caught in the staple line.
In this case, taking down the splenic flexure was not required to achieve sufficient mobility of the normal caliber colon to reach the pelvis.
The right lower quadrant port incision is extended to approximately 2.5 centimeters for specimen extraction.
A wound protector is applied to the right lower quadrant port site during specimen extraction.
The anvil component of an EEA circular stapler is placed into the lumen of the healthy colon and secured with a prolene purse string suture.
After returning the colon to the peritoneal cavity, a laparoscopic cap is applied over the wound protector to allow reestablishment of pneumoperitoneum.
The orientation of the colon is examined to ensure there is no twist as it passes into the pelvis.
After resection, the colon should lack redundancy and form a direct path into the pelvis.
The rectum is calibrated using scissors that come with the circular stapling device.
The EEA trocar is deployed adjacent to the rectal staple line until the orange tying area is seen.
The anvil is engaged into the trocar until a characteristic snap is felt.
The EEA device is closed until appropriate tissue compression is attained before firing.
Two complete doughnuts of colonic tissue should be present after firing, indicating a satisfactory anastomosis.
The integrity of the anastomosis is examined by filling the pelvis with saline and insufflating air into the rectum; absence of bubbling indicates no leak.
The patient was discharged on the 4th postoperative day following resumption of bowel function and establishment of diet and appendicostomy flushes.
The flush regimen was dramatically improved after resection, with plans to attempt transition to oral laxatives.