JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 18, Number 3, 2008

© Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2007.0142

Technical Report

Laparoscopic-Assisted Colostomy in Children

CLAUDIO DE CARLI, MD, MARCOS BETTOLLI, MD, CARL-CHRISTIAN JACKSON, MD,

BRIAN SWEENEY, MD, and STEVEN RUBIN, MD

ABSTRACT

Introduction: Colostomy morbidity has been reported to be as high as 50%. Laparoscopic-assisted

colostomy (LAC) is associated with decreased colostomy complication. LAC is recommended for
stoma formation in adults but has not been previously reported in children. In this paper, we re-
port on our initial experience with LAC in children.
Materials and Methods: Using a two- to four-port (3.5-mm) technique, LAC was performed in a
female with an imperforate anus and 2 male patients with complicated Hirschsprung’s disease (HD),
respectively. Data collected included operative time, time to recover bowel function, and morbidity.
Close follow-up was done until stoma closure.
Results: The operative time was 144 minutes in the HD patients (including concomitant laparo-
scopic biopsies and a leveling colostomy) and 40 minutes in the imperforate anus patient. Median
time to passage of both flatus and stool was 40 hours (range, 24–48). Time to commence feeds postop
was 40 hours (range, 24–48). The median time of follow-up was 3 months (range, 2–9) until the
stoma was taken down. No complications have occurred to date.
Conclusions: LAC is safe and easily performed in neonates and infants. It facilitates accurate
stoma placement and orientation. It allows additional bowel mobilization, especially in HD. In ac-
cordance with the adult experience, LAC seems to obviate stoma-related complications. Encouraged
by our initial low morbidity rate, a prospective evaluation of this technique is planned.

INTRODUCTION MATERIALS AND METHODS

C URRENTLY, LAPAROSCOPIC-ASSISTED COLOSTOMY

(LAC) is becoming the preferred method for fecal
diversion in adults.1 In neonates and children, open
colostomy is a well-established procedure. The stoma
complication rate may be as high as 50%.2 Multiple pro-
cedures for the revision of the colostomy are often nec-
essary.3–10 LAC in pediatric patients has not been de-
scribed to date. In this paper, we report on our initial
experience with LAC in infants.
Three patients underwent LAC. One female neonate had
anal agenesis (AA). Two male infants had Hirschsprung’s
disease (HD). The HD patients included a 3-month-old with
enterocolitis and a 15-month-old with a large bowel ob-
struction. HD was confirmed by rectal biopsies (hema-
toxylin and eosin; and neurofilament 68 and tubulin).11 The
following parameters were recorded: duration of surgery, re-
cover of bowel function, postoperative morbidity, compli-
cations of the stomas, indications, and conversion to open.

Division of Pediatric Surgery, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada.

481
482 DE CARLI ET AL.

FIG. 1. Scheme for ports placement in patients with
Hirschsprung’s disease requiring biopsies at the time of
colostomy formation. a, camera port; b, working ports; s, stoma
site.
FIG. 2. Scheme for ports placement in patients with anorec-
tal malformation. a, camera port; b, working port; s, stoma site.
RESULTS

Surgical technique The operative time in the HD infants was 144 minutes,
including leveling biopsies. In the neonate with the im-
Prior to the surgery, with the patient supine, the port perforate anus, surgical time was 40 minutes. The me-
sites, including the stoma position, were carefully marked dian time to passage of stools and commencement of
on the abdominal wall. Using the Hasson technique at the feeding was 40 hours (range, 24–48). There were no
umbilicus, the initial 3.5-mm port was inserted. conversions to laparotomy. In the HD patients, the
colostomies were closed after 2 and 3 months, at the time
HD. A 30-degree telescope is placed infraumbilically. of the Swenson rectosigmoidectomy. The newborn with
Three further 3.5-mm ports are introduced under direct AA remained with the colostomy for 9 months. No com-
vision in the epigastrium and the right lower and upper plications related to the procedure occurred. Stoma com-
quadrants. After placement of the trocars, the camera is plications have not occurred to date.
moved to the right upper quadrant (Fig. 1). The patient is
positioned in the Trendelenburg position. Following a
careful inspection of the colon from the rectum proxi-
mally, the transition zone is located by immediate histol-
ogy of seromuscular laparoscopic colonic biopsies until a
normal ganglionated colon without hypertrophic nerves
fibers is histologically confirmed. Having determined the
ideal site for the leveling colostomy, an appropriately
sized left lower quadrant incision is made. Using a Bab-
cock clamp introduced through this incision, an appro-
priate length of normal ganglionated colon is withdrawn
into the wound to allow the formation of the stoma at the
site of the most proximal seromuscular biopsy. A loop de-
functioning colostomy is then performed.13

Imperforate anus. With the position of the camera

supraumbilically, one more port was inserted in the right
lower quadrant in a contralateral position relative to the
stoma site (Fig. 2). After an inspection of the pelvic
anatomy, a defunctioning colostomy is created as de- FIG. 3. Laparoscopic view of the colostomy in a patient with
scribed above, ensuring a sufficient length of distal colon Hirschsprung’s disease. Notice the discrepancy between the dis-
is preserved to enable a comfortable correction of the tal aganglionic colon (right) and the proximal ganglionated
anorectal malformation. bowel (left).
LAPAROSCOPIC COLOSTOMY IN CHILDREN
DISCUSSION
Laparotomy for the colostomy in newborn and pedi-
atric patients is an established procedure.12,13 To decrease
the risk of complications, several modified techniques
have been used.3–10 Recently, the laparoscopic approach
has been utilized to correct stoma complications in pedi-
atric patients.14 Laparoscopic-assisted stoma closure was
used safely to take down the colostomy in 11 children.15
The advantages of LAC are well described in the adult
population.16 There is no reported experience with la-
paroscopy for colostomy in children. In this paper, we
described the technique of LAC in HD and imperforate
anus (intermediate and high). In these patients, the lap-
aroscopic approach allows an excellent visualization of
the abdominal cavity, even in those cases with bowel dis-
tention (Fig. 3). Stoma is created accurately in the cor-
rect segment of bowel, avoiding twisting the loops of the
colostomy during formation. Inclusion of the small in-
testine in the stoma and potential internal hernias can be
avoided.
In HD, leveling biopsies at the time of colostomy
formation are required. Mobilization of the colon, if
necessary, can be safely and accurately done, even in
the presence of long-segment HD. Tension of the limbs
of the colostomy can be avoided, thereby preserving
appropriate blood supply and preventing a retraction of
the stoma. In the patient with the anorectal malforma-
tion, laparoscopy may be useful to appreciate the
anatomy (e.g., the position of the fistula can be con-
firmed). Also, the bowel length can be conserved dis-
tally to facilitate the anorectal reconstruction. In
anorectal malformation, the suspicion of associated HD
can be confirmed with laparoscopic seromuscular biop-
sies and an appropriate ganglionated normal colostomy
can be performed.17
CONCLUSIONS
Our short experience with this technique showed a
promising method to create a colostomy in neonates and
children. Encouraged by our initial low morbidity rate, a
prospective evaluation of this simple technique is
planned.
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Address reprint requests to:
Steven Rubin, MD
Division of Pediatric Surgery
Children’s Hospital of Eastern Ontario
401 Smyth Road
Ottawa, Ontario, K1H 8L1
Canada
E-mail: rubin@cheo.on.ca
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