Laparoscopic repair of duodenal atresia: technical considerations

Duodenal atresia and stenosis is a frequent cause of congenital intestinal obstruction occurring in 1 per 5,000 to 10,000 live births, affecting boys more commonly than girls. Current operative techniques and contemporary neonatal critical care result in a very low morbidity and mortality rate (5%). The laparoscopic repair of duodenal atresia can be safely and successfully performed, the cosmetic benefits are considerable and results are encouragingly in favour of using this approach. In this video, Dr. Hossein Allal shows the laparoscopic approach for the treatment of duodenal atresia using four trocars.

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Laparoscopic repair of duodenal atresia: technical considerations

Authors

Abstract

Duodenal atresia and stenosis is a frequent cause of congenital intestinal obstruction occurring in 1 per 5,000 to 10,000 live births, affecting boys more commonly than girls. Current operative techniques and contemporary neonatal critical care result in a very low morbidity and mortality rate (5%). The laparoscopic repair of duodenal atresia can be safely and successfully performed, the cosmetic benefits are considerable and results are encouragingly in favour of using this approach. In this video, Dr. Hossein Allal shows the laparoscopic approach for the treatment of duodenal atresia using four trocars.

Catégorie

basic techniques

Mots-clés

Laparoscopic repair, duodenal atresia, technical considerations

Type de vidéo

Vidéo chirurgicale

Durée

09'00''

Publication

2009-06

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Jun 2009;9(06).
URL: http://www.websurg.com/doi-vd01en2666.htm

Laparoscopic repair of duodenal atresia: technical considerations

1. Patient and trocar position 00'10''

Laparoscopic surgery for the treatment of duodenal atresia is undertaken in a child strictly placed in a supine position. The pneumoperitoneum is established by a Hasson’s technique using a 5mm port. A purse-string allows to avoid leakage. It is also used to set the trocar in place. Under visual control, 3mm ports are introduced in the right and in the left flank to accommodate operating instruments. A third port in the xiphoid process and a 4th one in the left iliac fossa sometimes contribute to a good exposure of the operative field.

2. Duodenal dissection 01'28''

Freeing of the duodenal upper pouch and here of the duodenal lower pouch helps to create the anastomosis properly. The superior duodenal recess is sometimes attached by a transparietal stitch in order to better expose the duodenotomy as it is performed here.

3. Duodenotomy 02'04''

Here a transverse duodenotomy is achieved. It can be done by a coagulating hook since the wall is thick and there is no risk of devascularization. The duodenotomy should be large, transverse and caudally orientated. In duodenal atresia, the operative space is sometimes hindered by the presence of the liver and the xiphoid probe helps to retract it. The inferior duodenal recess is opened lengthwise. Its division must be carried out cautiously in order to avoid a transfixing cut of the posterior wall and avoid any injury to the common bile duct and to the Vater’s ampulla. Here this is a form situated above the Vater’s ampulla since the flow of bile fluids originates from the inferior duodenal recess. The duodenotomy should be sufficiently large. Since the duodenal walls are fragile, they have to be manipulated carefully and atraumatically.

4. Duodenal anastomosis 04'07''

An interrupted stitch is placed on the posterior margin of the upper duodenum and on the posterior margin on the lower duodenum respectively. This stitch is essential since it allows to approximate the 2 recesses. This is a full stitch, which grasps the muscularis mucosae and the mucosa. Stitches are knotted intracorporeally. Any excessive traction should be avoided as it could tear the gastric wall. Some experts recommend the use of a trans-anastomotic probe. In our experience, we prefer to create an anastomosis without it. This maneuver can sometimes cause a trauma to the suture and endanger the anastomosis. We generally use interrupted stitches; here the use of a running suture may be considered at risk since it may lead to leakage as the margins should be perfectly approximated. Surgery for duodenal atresia is sometimes difficult when the transverse colon impairs the exposure. In other cases, the duodenum falls into this area, and accessing it becomes troublesome. The liver can be retracted cephalad using a transparietal stitch, which lifts up the round ligament and then maintains the liver upward. Here the exposure is adequate. The posterior wall of the duodenum has been beautifully sutured. We then approximate the anterior wall. An interrupted stitch is used to bring the anterior margins together facing each other, which will then improve the suturing on each side of the anastomosis. Food intake can be resumed on the 3rd postoperative day and the length of hospital stay is approximately 14 days on average. The cosmetic benefits are considerable and results are encouragingly in favour of using this approach.