Laparoscopic duodenal derotation due to superior mesenteric artery syndrome

  • Abstract
    Introduction: Wilkie’s Syndrome, also called the Superior Mesenteric Artery Syndrome (SMA) is a clinical entity characterized by compression of the 3rd portion of the duodenum between the aorta and the emergence of the SMA. It is a rare cause of duodenal obstruction with around 400 cases reported in the literature. Methods: this video illustrates the case of a 50 year-old patient with a history of ankylosing spondylitis and cholecystectomy by laparotomy. She was admitted at the Emergency Room with a story suggestive of high intestinal obstruction. During hospitalization, a CT-scan was performed suggesting the existence of a mesenteric clamp. This etiology was confirmed after evaluation of the abdomen with Magnetic Resonance Imaging the next day. Results: the patient was subjected to a laparoscopic duodenal derotation, with resolution of clinical symptoms. Conclusions: duodenal derotation can be sufficient to treat this pathology. The laparoscopic approach, when performed by an experienced laparoscopic surgeon and using the same principles of laparotomy, should be preferred. It allows a better visualization of anatomical structures and a better patient recovery.
  • 00'12" Case presentation and exploration of abdominal cavity
    This film reports the clinical case of a 50-year-old, very thin woman (BMI of 19), with a background of ankylosing spondylitis and cholecystectomy. The patient presented to the emergency room with an obstructive bowel occlusion. The preoperative work-up raised the possibility of a Superior Mesenteric Artery (SMA) syndrome. After a period of medical treatment which was not tolerated by the patient, a laparoscopic duodenal derotation was proposed and performed two months after this acute episode. In the exploration of the abdominal cavity, the stomach did not prove too dilated and presented no thickened walls. There is an adhesion on the anterior abdominal wall probably due to the previous open cholecystectomy. Four trocars were used in this surgery (one 10mm trocar —perumbilical—, and three 5mm trocars —right and left hypochondrium, and left flank). The inferior surface of the liver is adherent to D1.
  • 01'44" Identification of Treitz’s flexure and first jejunal loop
    The transverse colon and the mesocolon are then suspended to identify the first loop and the angle of Treitz, as can be seen here. The superior mesenteric vein and the aorta are identified to the right.
  • 02'16" Release of connective tissue adherent to Treitz’s flexure
    Surgery consists in releasing the whole connective tissue adherent to the angle of Treitz. The dissection is carried out using Ultracision® to minimize blood losses while taking advantage of the existent anatomical planes.
  • 02'44" Dissection of upper surface of 4th duodenal portion
    Dissection is started on the upper surface of the fourth duodenal portion. The aorta, the superior mesenteric vein and the duodenum can be seen here in an anterior plane. The dissection of the upper surface of the duodenum is carried on until the identification of the superior mesenteric artery. The duodenum is freed from the aorta.
  • 03'35" Identification of superior mesenteric artery
    The superior mesenteric artery is identified. The superior mesenteric artery is moved aside and the duodenum is freed from the surrounding structures by means of the ultrasonic Ultracision® while carefully using the laparoscopic instruments.
  • 04'19" Freeing of posterior surface of 3rd duodenal portion
    The posterior surface of the third duodenal portion is in contact with the pancreas.
  • 04'44" Liberation of the underside of 3rd duodenal portion
    The underside of the third duodenal portion is now freed.
  • 05'17" Release of upper surface of duodenum using a posterior approach
    The upper surface of the duodenum is now freed, initially using a posterior approach.
  • 06'01" Release of anterior duodenal surface
    The anterior duodenal surface is eventually freed.
  • 06'13" Final aspect of structures after surgery. Treitz’s flexure and the 3rd duodenal portion should be checked and completely freed.
    This is the final look of the structures after surgery. The angle of Treitz and the third duodenal portion should be checked and completely freed.
  • 06'32" The defect created is filled with intra-abdominal fat
    The defect created is filled with intra-abdominal fat. There are no postoperative complications and the patient is discharged on the second postoperative day. She remains asymptomatic after one year.
  • Related medias
    Introduction: Wilkie’s Syndrome, also called the Superior Mesenteric Artery Syndrome (SMA) is a clinical entity characterized by compression of the 3rd portion of the duodenum between the aorta and the emergence of the SMA. It is a rare cause of duodenal obstruction with around 400 cases reported in the literature. Methods: this video illustrates the case of a 50 year-old patient with a history of ankylosing spondylitis and cholecystectomy by laparotomy. She was admitted at the Emergency Room with a story suggestive of high intestinal obstruction. During hospitalization, a CT-scan was performed suggesting the existence of a mesenteric clamp. This etiology was confirmed after evaluation of the abdomen with Magnetic Resonance Imaging the next day. Results: the patient was subjected to a laparoscopic duodenal derotation, with resolution of clinical symptoms. Conclusions: duodenal derotation can be sufficient to treat this pathology. The laparoscopic approach, when performed by an experienced laparoscopic surgeon and using the same principles of laparotomy, should be preferred. It allows a better visualization of anatomical structures and a better patient recovery.