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Laparoscopic Duodenoduodenostomy

Simon Clarke BSc MBBS FRCS (Eng) FRCS Paed Surg

Consultant Paediatric Surgeon Chelsea & Westminster Hospital , London

Honorary Senior Lecturer Imperial College

As minimal access surgery in neonates became increasingly reported over a decade ago, preliminary reports of the laparoscopic approach being used to treat congenital duodenal obstruction began to emerge.

Principles of Laparoscopic Duodenoduodenostomy

As in the open approach, adequate exposure with identification of the proximally dilated duodenum and the collapsed distal segment is essential, followed by the creation of a diamond shaped anastomosis. Potential advantages of the laparoscopic approach are reduced bowel handling, earlier resumption of feeds, fewer adhesions and improved cosmesis. The magnification of the anastomosis also allows for a significantly improved operative view. Completion of the procedure however requires advanced laparoscopic skills.

Diagnosis

The diagnosis of duodenal atresia is usually made prenatally with a double bubble type appearance on prenatal ultrasound and confirmed with a postnatal abdominal radiograph.

Contraindications to laparoscopic repair

Low birth weight maybe considered a relative contraindication, though successful published reports are described in 1.3kg infants.

Pre operative preparation

The diagnosis is confirmed usually with a postnatal radiograph. A double bubble appearance confirms the diagnosis. If sparse distal gas is seen then an incomplete stenosis is a possibility. Echocardiogram is often performed to exclude congenital heart disease.

Anaesthesia

The procedure requires endotracheal intubation with general anaesthesia in a suitably warmed operating theatre environment.

Patient positioning

The supine infant is either placed end of the operating table or across and at the end of the table. The operating surgeon stands at the infant’s feet with the cameraman to the surgeons left and scrub team on the right. A warming blanket surrounding the infant is advisable. The bladder is emptied by the Crede method of gentle suprapubic pressure.

Laparoscopic instrumentation and sutures

• 5mm optical endoscope 30 degree

• 3mm needle holder

• 3mm Kelly forceps

• 3mm scissors

• 3 mm soft bowel grasper

• 2’0; 4’0; 5 ‘0 or 6’0 polydioxanone suture

OPERATION

1 Port placements

• 1 x 5mm supraumbilical port is placed under direct vision. A securing purse string suture is advisable to avoid peritoneal leak of carbon dioxide and for port stability.

• 1 x 3 mm port in the left lateral quadrant just above umbilicus with a latex catheter cuff to allow a securing suture.

• 1 x 3mm port in the right lateral quadrant just below umbilicus with a latex catheter cuff to allow a securing suture.

Insufflation

• 5 – 8 mmHg CO2 at a flow of 1l/ min

Procedure

The liver may obscure the initial view of the duodenum. To visualize the duodenum a 2-0 monofilament suture can be taken into the abdomen and out again through the upper abdominal wall gently hitching up the falciform ligament in its path. This is then tied onto the abdominal wall surface over a pledget to avoid marks on the abdominal wall skin. Alternatively a 3mm grasping instrument can be inserted in to the left epigastric area to directly elevate the liver.

Once the liver is lifted the dilated duodenal pouch is usually visible. The hepatic flexure of the colon is mobilized to fully expose the duodenum. The dilated duodenum is then released from the surrounding anterior peritoneal attachments (kocherisation) and the distal collapsed segment identified. The dissection is best carried out using the Kelly forceps and soft bowel grasper. Care must be taken to avoid injury to the pancreas and common bile duct.

2 Once identified, stabilisation of the proximal pouch is essential by inserting one or two 4-0 stay sutures to the proximal pouch. Once inserted through the abdominal wall, the needle can be placed in the dilated duodenum and then taken back out and again tied onto a pledget on the abdominal wall. This now stabilises the upper pouch ready for the anastomosis.

3a A transverse incision is initially made on the upper pouch using a 3mm hook diathermy and then and extended with scissors. Care must be taken not to generate too much heat with the hook as the ampulla maybe nearby. A 3mm sucker can be introduced if bile is seen. A 10 – 15mm incision is usually sufficient and is followed by a similar sized longitudinal incision along the distal collapsed segment. Care must be taken when handling the delicate tissue of the distal bowel.

The bowel graspers can be used to gently prise open the two incisions. A separate 5-0 or 6-0 polydioxanone suture can be introduced at this point.

3b The distal collapsed duodenum can then be fixed to the upper pouch incision at the superior and inferior apical points of the intended anastomosis. If the initial superior apical suture is also brought out of the abdominal wall as a stay suture then further stability is afforded for the remainder of the anastomosis.

The posterior wall is then be sutured using interrupted or a continuous suture layer with knots tied intracorporeally. Knots lie within the lumen of the bowel for the posterior layer. The anterior layer is then completed with extraluminal knots. If the operator’s usual practice is to flush the distal bowel with saline then this can attempted before final anastomotic closure though this can be cumbersome. An inspection by walking the bowel can also be carried out and obvious atresias identified. The association of distal atresia with duodenal atresia is less than 2 %.

Once the anastomosis is complete the abdomen should be desufflated and the ports removed under direction vision to avoid extraction of omentum. All wounds, including the 3mm, are then closed with 4-0 vicryl. Skin can be closed with either tissue glue or suture.

If at first the dilated duodenum and distal bowel appear in continuity, then an intrinsic web may be the obstructive cause. In this situation duodenoduodenostomy is still preferred with partial web excision to allow for continuity and avoid injury to the ampulla.

Potential pitfalls

• Injury to pancreas or Common bile duct during kocherisation

• Injury to ampulla during anastomosis

• Incomplete examination of distal bowel to exclude atresia or web

• Anastomotic leak

Post operative care

Nasogastric tube decompression and intravenous feeding is continued until the volume of aspirates has reduced. Feeds are then usually introduced slowly. Medication for gastro- oesophageal reflux may be required.

Further reading

Rothenberg SR. Laparoscopic duodenoduodenostomy for duodenal obstruction in infants and children. J Pediatr Surg 2002;37:1088-9.

Spilde TL, St Peter SD, Keckler SJ, et al. Open vs laparoscopic repair of congenital duodenal obstructions: a concurrent series. J Pediatr Surg 2008;43:1002-5

Kay S, Yoder S, Rothenberg S. Laparoscopic duodenoduodenostomy in the neonate.J Pediatr Surg. 2009 May;44(5):906-8

David C. van der Zee. Laparoscopic Repair of Duodenal Atresia: Revisited World J Surg. 2011 August; 35(8): 1781–1784

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