Appendicostomy :: Nationwide Children's Hospital

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Appendicostomy (Malone Procedure or MACE)

An appendicostomy (said like: a pen di KOSS tuh me) or Malone, can be done for children who need an enema every day to stay free from stool accidents. This lets the child give himself or herself the enema. An appendicostomy, or Malone procedure (MACE), is a surgery that makes a pathway from the belly button into the colon. Enema fluid will go through this pathway. With the Malone procedure, the enema can be given at the beginning of the colon (appendix), instead of being flushed up through the rectum. The flush is then from the top down, rather than bottom up.

The surgeon connects the appendix to the belly button (umbilicus) or right corner of the belly (abdomen). A one-way valve is created inside your child’s belly. This lets the enema tube (catheter) go in, but no stool or body fluids will be able to come out. The valve is hidden on the inside. No artificial device is used. The surgeon makes the valve with your child’s natural tissues and skin. The Malone tube (catheter) can be inserted through this valve. The solution can be flushed through the new valve the same as a rectal enema (Picture 1).

Before Surgery 


  • One day before the surgery, your child will get a rectal enema. This will clean out the colon before surgery. 
  • Your child will not be able to eat anything after midnight. 

Day of Surgery 

  • The day of the surgery, your child will arrive at the hospital 2 hours before surgery time. 
  • Surgery takes about 1 hour and is done with a scope through a small cut (incision) in your child’s belly. 

Care After Surgery 

  • Your child will, most likely, stay in the hospital for 2 days after surgery. This is to make sure there are no problems and gives you time to learn your child’s flush routine.
  • Your child can usually eat a regular diet the morning after surgery. 
  • One week after surgery, your child can do normal physical activities, like gym and sports. Your child may also bathe, shower, and swim normally.
  • The doctor will insert a small tube during surgery that will stay in your child’s belly button. The tube will go into the appendix. Enema fluid will be flushed through this tube. The tube will stay in place for one month, and then will be removed in the clinic.
  • When the tube is removed, an ACE stopper will be put in its place. This stopper keeps the appendicostomy valve in the belly button open. The stopper is made of silicone. Do not use it if your child has a silicone allergy.
  • At the clinic, the healthcare team will teach you how to insert the Malone catheter and give the enema at home.

Flushing the Appendicostomy 

Before you leave the hospital, the healthcare team will make sure you know how to flush the Malone. They will teach you what to put in the flush solution. They will teach you how many times a day to flush through the Malone.


Follow these steps when giving an enema through the appendicostomy: 

  1. Put the supplies in the bathroom:
    - Enema bag 
    -Malone catheter
    - Enema solution (as ordered by your child’s doctor)
    - Timer
    - Games, books, or other activities to help your child pass the time
    - Water-based lubricant 
  2. Wash your hands with soap and water. 
  3. Close the clamp on the enema bag. 
  4. Add prescribed enema fluid to the bag. 
  5. Remove air from the tubing by opening the clamp and letting fluid run. Close the clamp. 
  6. Hang the bag on the shower curtain rod or a wall hook. 
  7. Seat your child on the toilet. Insert the catheter into the belly button valve about 3 to 4 inches. 
  8. Open the clamp and allow the solution to run in over 5-10 minutes. If your child has cramps, slow down the flow by adjusting the clamp. 
  9. When all the liquid has gone in, close the clamp. Remove the catheter from the belly button. 
  10. Wait for the solution to work and your child to empty his bowel. This usually takes 30 to 60 minutes. Massaging the belly firmly from right to left may help to empty the bowel faster. 
  11. Rinse the enema bag well with warm water, and wash with soap and water. Allow to air-dry before putting it away.

Placing the ACE Stopper 

Follow these steps when placing the ACE stopper:

  1. Clean and dry the valve site with soap and warm water. 
  2. Put the water-based lubricant on the end of the ACE stopper so it will go in easier. 
  3. Gently insert the stopper until the disc of the stopper is flat against your child’s belly. 
  4. You can keep the stopper in place by putting a Band-Aid® or tape over top of it. Change the dressing every day to keep the site clean and free from irritation.
  5. Call the nurse if your child’s skin gets irritated or if you are not able to insert the ACE stopper.

Important Things to Remember 

  • If your child has had his or her appendix removed, this surgery can still be done. The surgeon can create a new one from a piece of the colon. It will work just like a regular appendicostomy. 
  • Do not throw away the enema bag, tubing, or catheter. They will be used over and over again. 
  • Do not use any solvent, such as alcohol or acetone, to clean the tube. Only use tap water. 
  • Enemas may be adjusted. This depends on your child’s bowel response. 

When to Call the Doctor 

Call your child’s doctor if any of these things occur: 

  • Discomfort or pain around the belly button 
  • Skin irritation, like redness or drainage 
  • Fever over 101 degrees F axillary (under the arm) 
  • Feeling sick to the stomach (nausea)
  • Unable to insert the Malone catheter

Appendicostomy (PDF)

HH-I-365 6/14, Revised 6/16 Copyright 2014, Nationwide Children’s Hospital

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