MACE Procedure

MACE procedure

The MACE, also referred to as the Malone procedure or ACE (Antegrade Continence Enema), is a surgical method that allows patients—typically children—who have been struggling with chronic constipation or fecal incontinence to manage their condition more effectively after other medical options have failed.

What is the MACE Procedure?

The MACE procedure forms a small, continent channel (usually with the use of the appendix) between the colon and the skin. Enemas may be administered through this channel from above (antegrade), resulting in a very clean, dependable bowel movement. 

Indications for use include:

• Neurogenic Bowel (Spina Bifida, SCI)
• Constipation that is chronic and unresponsive
• Fecal incontinence
• Anorectal malformations
• Hirschsprung disease (bowel dysfunction after surgery)
• Cerebral palsy or other neuromuscular diseases

Types of MACE Procedures

Appendicostomy (Classic Malone procedure)

• Channel is created using the appendix

Cecostomy-based MACE

• Employed when the appendix is missing or inappropriate

Laparoscopic MACE

• Less invasive, quicker recovery

Procedure 

• Done under general anaesthesia
• Appendix or bowel segment located
• An end is affixed to the colon (cecum)
• Other end is exteriorized (usually at the umbilicus or right lower abdomen)
• A continent valve is formed to avoid leakage
• Small stoma is created for catheter insertion
• Surgical time: 1-2 hours

Postoperative Care & Enema Routine

• Enemas were commenced after healing (2–3 weeks)
• Through stoma, catheter inserted
• Saline or a medicinal solution is flushed
• Bowel movement occurs within 30 to 60 minutes
• How often: Daily or every other day

Pediatric MACE procedure

Child­ren undergoing the MACE procedure typically stop using other bowel medications, including laxatives and enemas.

Pediatric MACE types

Appendicostomy (Classic Malone)

• Appendix as Conduit (In preference)

Neo-appendicostomy

• With small bowel or cecal flap if appendix not found

Pediat­ric Laparoscopic MACE

• Minimally invasive, most common today

Cecostomy-based ACE

• Alternative to appendicostomy

Procedure

• General anaesthesia
• Sequencing: Selecting appendix or bowel segment
• Nipple valve creation
• Stoma creation (usually at the umbilicus for cos­metic reasons)
• Catheter placement for healing
• Surgical time: 60–120 minutes

Recovering (Children)

• Length of hospital stay: 3–5 days
• Parental instruction in stoma care
• Enemas started after 2 to 3 weeks
• Gradual enema volume adjustment
• Daily or every other day bowel program

MACE procedure recovery

Outcomes following the MACE procedure are generally uneventful and predictable, particularly in the pediatric age group, when appropriate stoma care and bowel training are instituted. Here is a straightforward summary, stage by stage. 

Day 1–3 Postoperative Recovery

• Duration of hospital stay: 3–5 days 
• Outstanding Result Mild abdominal pain treated with analgesics
• IV fluids → gradual oral feeding
• Stoma catheter left in position for keeping the channel open
• Early mobilization encouraged

Part 2: Early Healing Phase (Week 1–3)

• Child goes home with catheter in situ
• Stoma daily cleaning with saline solution
• No enemas yet (let channel heal)
• Refrain from strenuous activity, cycling and swimming
• Normal diet gradually re-established

Beginning of enema protocol (Week 2–3)

• Enemas initiated under medical supervision
• Catheter inserted via MACE stoma
• Saline ± glycerin / additives - common solutions
• Defecation of the bowel is done within 30 - 60 minutes
• Frequency: Once daily or every other day

Intermediate Recovery (Weeks 4–6)

• Between flushes, the catheter may be uncoupled from the collecting bag.
• Kid learns self-catheterization (age appropriate)
• Return to school: 2–3 weeks
• Stoma becomes stable and easy to access

Long Term Recovery & Adaptation (After 6 Weeks)

• Predictable bowel routine after established
• No rectal enemas needed
• Greater continence and confidence
• Minimal follow-up care required
• Regular follow-up visits

Diet During Recovery

• High-fiber diet (as directed)
• Good hydration
• Avoid eating any constipation -inducing foods at first
• Keep your meals regular

Laparoscopic MACE procedure

The laparoscopic MACE procedure is a MACE operation performed laparoscopically, which is less invasive and is usually performed on children with severe constipation or fecal incontinence, which are unresponsive to medical treatment.

What Is a Laparoscopic MACE? 

In this procedure, the surgeon makes keyhole (laparoscopic) incisions to construct a continent channel—typically through the appendix—between the skin and the cecum. This enables antegrade enemas to be administered for predictable bowel evacuation.

How the Laparoscopic MACE Is Performed?

• General anaesthesia
• 3–4 small laparoscopic ports inserted
• Appendix identified and mobilized
• One end is fixed to the cecum
• Continent valve mechanism created
• Appendix brought to skin (umbilicus or right lower abdomen)
• Temporary catheter placed
• Operating time: 60–120 minutes

Additional Benefits of Laparoscopic MACE

• Smaller scars
• Less postoperative pain
• Faster recovery
• Shorter hospital stay
• Better cosmetic outcome (often hidden in umbilicus)
• Lower wound infection risk

After Surgery

• Hospital stay: 2–4 days
• Oral feeds resumed early
• Catheter retained for 2 to 3 weeks
• Enemas started after healing
• Parents trained in stoma care

Best hospital for MACE procedure India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Laparoscopic MACE appears to be a safe and effective treatment modality in a select group of patients, especially children, with severe constipation or fecal incontinence resistant to medical therapy. Improves hygiene and quality of life It permits a predictable, antegrade emptying of the bowel through a small, continent stoma, thereby enhancing hygiene, independence and quality of life. With proven long-term success rates, low complexity, and manageable morbidity, the MACE has been established as the preferable bowel management modality for children with neurogenic bowel, anorectal malformations, and post-Hirschsprung disease motility complications. When executed in combination with good patient selection, education of caregivers, and consistent follow-up, the procedure has high rates of long-term success and continence, allowing children to more confidently participate in daily and social activities.

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FAQ

1. From what age can the MACE be done?

• It is usually carried out in children at the age of 4-6 years, but can be earlier if clinically indicated.

2. Is the MACE procedure permanent?

• Yes, it’s intended as a permanent intervention, but it can be reversed if it’s no longer required.

3. Is laparoscopic MACE better than open surgery?

• Yes. Laparoscopic MACE leads to smaller scars, less pain, faster recovery and better cosmetic results.

4. Will My Child Need Laxatives after Mace? 

• Most children no longer need laxatives by the time they get a good MACE bowel program established.

5. Is it safe to do daily catheterization?

• Yes. Catheterization regularly is safe and it may help stoma patency.

6. Will the stoma be visible?

• It is frequently installed at the umbilicus for a discreet and cosmetically acceptable location.