Introduction & Objective :
Laparoscopic surgery is useful in pediatric urologic reconstruction especially in those who have undergone prior abdominal surgeries and in settings where robotics is unavailable. Minimally invasive surgery has been shown to help with reduction in postoperative pain, narcotic requirements and hospital length of stay. We present our never-before described case of laparoscopic-assisted Monti ileovesicostomy takedown and provide our insight on useful techniques to aid a potentially cumbersome procedure.
Our patient is a 15-year-old male with a history of VATER association. His prior surgeries include bilateral Cohen ureteral reimplant; left pyeloplasty and redo left reimplant with Boari flap; Mic-Key cecostomy button placement; and ileovesicostomy. He suffered from urinary leakage per Monti channel. Urodynamics showed good bladder capacity and EMG-uroflow demonstrated ability to empty. He elected for laparoscopic-assisted Monti takedown.
Surgical port placement included a 5 millimeter camera port in the upper midline and two working 5 millimeter ports in the right and left upper quadrants. An additional 3 mm laparoscopic grasper was placed in the left midclavicular line. Bowel adhesions to the Monti channel and anterior abdominal wall were lysed. Three main technicical points to highlight are 1) using a bougie in the Monti channel allows manipulation of the channel and provides counter-traction during dissection; 2) placing a foley catheter into the Monti channel with balloon inflated in the bladder provides clear delineation of the distal extent of dissection; and 3) using V-loc barbed wound closure sutures allows for easier laparoscopic suturing and obviates the need to perform laparoscopic instrument tying. The Monti channel was sharply dissected from the umbilicus down to where the channel was already freed up intracorporeally, and the channel was removed. A suprapubic tube was placed.
Once admitted to the hospital after surgery, the patient required no narcotic pain medication. He was discharged on postoperative day 1 with an unremarkable hospital course. A VCUG was obtained on postoperative day 12 which showed no urinary extravasation. He has not had any postoperative complications.
Conclusions : Ileovesicostomy takedown can be performed safely with laparoscopic assistance. This technique allowed for quick recovery, minimal additional scars, minimal use of pain medications and short hospital stay. External manipulation of the Monti channel and use of barbed suture aids surgical ease.
Kelly Swords– Assistant Clinical Professor, UCSD/Rady Children's Hospital San Diego, San Diego, California
Hoang-Kim Le– Pediatric Urology Fellow, University of California San Diego, San Diego, California
Sunil Patel– Resident, University of California San Diego, San Diego, California
George Chiang– Associate Professor, University of California San Diego, San Diego, California
Assistant Clinical Professor
UCSD/Rady Children's Hospital San Diego
San Diego, California
Dr. Kelly Swords is a board-certified pediatric urologist at Rady Children's Hospital-San Diego. After earning her medical degree at the University of North Carolina at Chapel Hill, Dr. Swords went on to complete a residency in urology at the University of South Florida. She then continued her medical education with a pediatric urology fellowship at Children's National Health System, where she was trained in pediatric urology robotic surgery.
Dr. Swords's clinical and research interests include the minimally invasive surgery, medical education, and improving healthcare costs and access. She
Pediatric Urology Fellow
University of California San Diego
San Diego, California