(1)
Paediatric Surgery, Gold Coast University Hospital, Queensland, Australia
Abstract
Laparoscopic duodenal atresia repair (duodenoduodenostomy) was initially described at the beginning of the twenty-first century; some centres abandoned the laparoscopic approach due to high anastomotic leak rates [1]. One particular centre [1] reported an anastomotic leak rate of just under 30 %, in their initial early series before abandoning the procedure for some time. After modifying their technique from interrupted to continuous suturing, they revisited the procedure in a new cohort of patients and, with this, had no complications. As a result, they have been performing and teaching the procedure ever since. Others have also reported similar results [1]. They have themselves suggested that laparoscopic duodenoduodenostomy should be restricted to paediatric centres with extensive laparoscopic experience.
Keywords
Laparoscopic duodenal atresia repairDuodenoduodenostomy20.1 General Information
Laparoscopic duodenal atresia repair (duodenoduodenostomy) was initially described at the beginning of the twenty-first century; some centres abandoned the laparoscopic approach due to high anastomotic leak rates [1]. One particular centre [1] reported an anastomotic leak rate of just under 30 %, in their initial early series before abandoning the procedure for some time. After modifying their technique from interrupted to continuous suturing, they revisited the procedure in a new cohort of patients and, with this, had no complications. As a result, they have been performing and teaching the procedure ever since. Others have also reported similar results [1]. They have themselves suggested that laparoscopic duodenoduodenostomy should be restricted to paediatric centres with extensive laparoscopic experience.
Advantages of the laparoscopic approach include faster recovery and earlier resumption of oral feeding, leading ultimately to earlier discharge.
20.2 Relevant Anatomy
There are three categorised types of duodenal atresia. Type 1 involves either a diaphragm or web that includes submucosa and mucosa. Type 1a is termed the “windsock” deformity, where the diaphragm has ballooned distally. 1b involves a membrane without ballooning, whereas 1c involves a web between the duodenal segments. Type 2 atresias have a dilated proximal segment, with collapsed distal segment connected by a fibrous cord. Type 3 atresias have no connection between proximal and distal segments. Most atresias occur at the level of D2 (Fig. 20.1).
More than 50 % of duodenal atresias are associated with other congenital anomalies, and approximately 30 % are associated with trisomy 21. Other associations include cardiac anomalies and other gastrointestinal abnormalities, the most important of which to recognise is malrotation.
Diagnosis may be made antenatally, with findings of a double bubble sign. Most were detected within the seventh and eighth months of pregnancy.
Although the duodenum has numerous close anatomical relations, those most important in laparoscopic duodenoduodenostomy include:
- 1.
The falciform ligament: containing the left umbilical vein, it should not be transected but carefully secured superiorly to retract the liver.
- 2.
The right lobe of the liver: in infants, the liver is quite large with respect to the abdominal cavity size and hangs over the duodenum.
- 3.
The transverse colon: also overlying the duodenum, it must be gently peeled away from the duodenum to get exposure.
- 4.
The pancreas: locating the pancreas helps identify the proximal and distal parts of the duodenum in duodenal atresia as it generally separates the two. In some cases, an annular pancreas may be identified
Fig. 20.1
There are three categorised types of duodenal atresia. Type 1 involves either a diaphragm or web that includes submucosa and mucosa. Type 1a is termed the ‘windsock’ deformity, where the diaphragm has ballooned distally. Type 1b involves a membrane without ballooning, whereas type 1c involves a web between the duodenal segments. Type 2 atresias have a dilated proximal segment, with collapsed distal segment connected by a fibrous cord. Type 3 atresias have no connection between proximal and distal segments. Most atresias occur at the level of D2
20.3 Working Instruments
