Introduction With the ongoing expansion of indications for endo- scopic pediatric surgery and increasing experience with intracorporeal suturing, laparoscopic repair of duodenal atresia or stenosis is the challenge of the new century. In 2001 the first laparoscopic repair of a duo- denal atresia was described by Bax et al. (2001), short- ly followed by Rothenberg (2002) describing a series of four patients. ereaſter a few other publications have appeared (Gluer et al. 2002; Nakajima et al. 2003). Precise anatomical knowledge is necessary to deter- mine the distal duodenum that runs posteriorly and needs to be mobilized to perform a diamond-shaped anastomosis (Kimura et al. 1977, 1990). Laparoscopic correction of jejunal atresia has not been described so far which is not surprising as the proximal jejunum is usually strongly dilated, which necessitates tapering. Preoperative Preparation Before Induction of General Anesthesia In duodenal atresia associated anomalies including cardiac ones are frequent and about 30% of the patients have Down syndrome. ese patients therefore require a thorough diagnostic workup before surgery. Most congenital cardiac anomalies, apart from duct-depen- dent cardiac lesions, are compatible with safe extracar- diac minimal access surgery in neonates and young infants (van der Zee et al. 2003). It is important to know that associated intestinal malrotation is present in about 20% of the patients. Timing of surgery is elective and may be delayed in case of extreme prematurity, or when cardiac surgery is warranted first. A nasogastric tube is placed to decompress the stomach. After Induction of General Anesthesia Part of the perioperative management may be subject to local customs and personal preferences. Future porthole sites may be injected with local anesthetics. Laparoscopic Treatment of Duodenal and Jejunal Atresia and Stenosis David C. van der Zee and Klaas (N) M.A. Bax Chapter 39 Epidural or spinal anesthesia is subject to the per- sonal preference of the anesthetist. If the patient is re- ceiving analgesia by means of an epidural catheter a voiding urinary catheter is placed and leſt in postop- eratively for the duration of the epidural analgesia. All patients receive antibiotics perioperatively according to local customs. Positioning Patient e patient is placed in a supine position with the table in a 15–20° reversed Trendelenburg position. In in- fants and small children the legs are bent in a froglike position on a short operating table with the operation table sheet wrapped around them to prevent the child from sliding down. Crew, Monitors, and Equipment In infants and small children the surgeon stands at the lower side of a short table with the assistant, who holds the camera, on the surgeon’s leſt side ( Fig. 39.1). It is oſten an advantage to have this person sitting down, thus obtaining a more stable picture. e scrub nurse stands on the surgeons’ leſt or right hand, depending on whether the surgeon is right- or leſt-handed, re- spectively. Preferably two monitors are used on either side of the patient’s head. Usually one monitor is inte- grated into the equipment on the endoscopy tower. If the separate monitor is fixed to a flexible arm, the monitor is placed just over the patient’s chest to obtain the optimal position for vision and handling. Special Equipment No special instruments are required and monopolar high frequency electrocautery suffices as the energy applying system.
Transcript
Introduction
With the ongoing expansion of indications for endo-scopic pediatric surgery and increasing experience with intracorporeal suturing, laparoscopic repair of duodenal atresia or stenosis is the challenge of the new century. In 2001 the first laparoscopic repair of a duo-denal atresia was described by Bax et al. (2001), short-ly followed by Rothenberg (2002) describing a series of four patients. Thereafter a few other publications have appeared (Gluer et al. 2002; Nakajima et al. 2003).
Precise anatomical knowledge is necessary to deter-mine the distal duodenum that runs posteriorly and needs to be mobilized to perform a diamond-shaped anastomosis (Kimura et al. 1977, 1990).
Laparoscopic correction of jejunal atresia has not been described so far which is not surprising as the proximal jejunum is usually strongly dilated, which necessitates tapering.
Preoperative Preparation
Before Induction of General Anesthesia
In duodenal atresia associated anomalies including cardiac ones are frequent and about 30% of the patients have Down syndrome. These patients therefore require a thorough diagnostic workup before surgery. Most congenital cardiac anomalies, apart from duct-depen-dent cardiac lesions, are compatible with safe extracar-diac minimal access surgery in neonates and young infants (van der Zee et al. 2003). It is important to know that associated intestinal malrotation is present in about 20% of the patients.
Timing of surgery is elective and may be delayed in case of extreme prematurity, or when cardiac surgery is warranted first. A nasogastric tube is placed to decompress the stomach.
After Induction of General Anesthesia
Part of the perioperative management may be subject to local customs and personal preferences. Future porthole sites may be injected with local anesthetics.
Laparoscopic Treatment of Duodenal and Jejunal Atresia and Stenosis David C. van der Zee and Klaas (N) M.A. Bax
Chapter 39
Epidural or spinal anesthesia is subject to the per-sonal preference of the anesthetist. If the patient is re-ceiving analgesia by means of an epidural catheter a voiding urinary catheter is placed and left in postop-eratively for the duration of the epidural analgesia. All patients receive antibiotics perioperatively according to local customs.
Positioning
Patient The patient is placed in a supine position with the table in a 15–20° reversed Trendelenburg position. In in-fants and small children the legs are bent in a froglike position on a short operating table with the operation table sheet wrapped around them to prevent the child from sliding down.
Crew, Monitors, and Equipment In infants and small children the surgeon stands at the lower side of a short table with the assistant, who holds the camera, on the surgeon’s left side ( Fig. 39.1). It is often an advantage to have this person sitting down, thus obtaining a more stable picture. The scrub nurse stands on the surgeons’ left or right hand, depending on whether the surgeon is right- or left-handed, re-spectively. Preferably two monitors are used on either side of the patient’s head. Usually one monitor is inte-grated into the equipment on the endoscopy tower. If the separate monitor is fixed to a flexible arm, the monitor is placed just over the patient’s chest to obtain the optimal position for vision and handling.
Special Equipment
No special instruments are required and monopolar high frequency electrocautery suffices as the energy applying system.
294 Abdomen – Gastrointestinal Tract
Technique
Cannulae
Cannula Method of insertion
Diameter (mm)
Device Position
1 Open 6 Optic, 30° Umbilicus
2 Closed 3.5 Curved grasping forceps Right lower quadrant
3 Closed 3.5 Hook, scissors, forceps Left hypochondrium
The first step of the procedure is to rule out the coexis-tence of intestinal malrotation. If there is a concomi-
tant malrotation, this should be corrected first as is described in Chapter 40.
The colon is mobilized sufficiently to the left to ex-pose the dilated bulbus and collapsed distal duode-num. The bulbus duodeni is lifted against the ventral abdominal wall with two 3 0 Vicryl transcutaneous stay sutures.
Fig. 39.1. Positioning of the patient, crew, and equipment
Chapter 39 295
The proximal part of the of the distal duodenum is identified and mobilized to facilitate a diamond-shaped anastomosis ( Figs. 39.3, 39.4). Care is taken to avoid opening of the mesentery of the colon.
The anterior wall of the distal duodenum is incised longitudinally and the anterior wall of the bulbus hori-zontally over a length of 1.5–2 cm. The anastomosis is made with standing Vicryl 5 0 sutures. The first su-ture is made from the corner of the incision of the dis-tal duodenum to halfway along the lower side of the opening in the bulbus. The following sutures run from the lower side of the opening in the bulbus to left and right of the distal duodenum until the corners of the opening in the bulbus are reached. Then the ventral anastomosis is made, also with standing sutures. It is sometimes of help to make the first stitch from halfway
along the upper side of the bulbus opening to the distal corner of the distal duodenum to have the distal duo-denum settle itself in its position against the bulbus. A transanastomotic tube is not placed, but injection of air into the stomach by the anesthesiologist can con-firm patency of the anastomosis and proximal jeju-num. Finally the anastomosis can facultatively be se-cured with TissueCol. No drain is left behind.
In case of a duodenal web, mobilization of the duo-denum is easy. As in open surgery, however, it may be difficult to determine the place where the web is ex-actly located. The duodenum should be pulled up against the anterior abdominal wall by means of stay sutures. Next the anterior duodenum is opened longi-tudinally and the web is searched for. If the web is found it should be partially excised taking care not to injure the bile duct which often opens into the edge of the opening of the web. Closure of the duodenum can be done with standing or running 5 0 Vicryl su-tures.
As in any complex endoscopic surgical operation, there should be a low threshold for conversion. Mobi-lization of the duodenum prior to conversion will al-low subsequent open surgery through a minilaparoto-my.
Postoperative Care
A nasogastric tube is left in place. Usually oral feeding can be started between day 3 and day 5 postoperative-ly. As at least half of the patients have Down syndrome oral feeding may be delayed. Intestinal feeding via the nasogastric tube is an alternative when the child is slow in drinking.
Fig. 39.2. Port positions
Fig. 39.3 a,b. Schematic drawing of the diamond-shaped anastomosis
296 Abdomen – Gastrointestinal Tract
Fig. 39.4. Actual endoscopic operation. a The dilated bulbus is clearly seen. b The bulbus is pushed upward. Below the bul-bus duodeni, there is a rim of pancreatic tissue. Below the pancreatic tissue the distal duodenum comes into view. c Lon-
gitudinal opening of the distal duodenum. d Transverse open-ing of the bulbus duodeni. e Suction of the bulbus duodeni through the transverse duodenotomy. f First stitch of the dia-mond-shaped anastomosis
Chapter 39 297
Fig. 39.4. Actual endoscopic operation. g Completed anas-tomosis
Results
In the period 2000 and 2004, 18 children with duode-nal or jejunal atresia or stenosis had a laparoscopic ap-proach. Seventeen children were operated in the neo-natal period and one infant at the age of 1 year. Nine out of the 17 children with duodenal atresia or stenosis had trisomy 21. Of the 17 children with duodenal atre-sia or stenosis, three had stenosis and one had a web. In four the duodenal atresia was combined with malrota-tion. Other associated malformations were: two esoph-ageal atresia type C, one esophageal atresia type A, one total colonic aganglionosis, two tetralogy of Fallot, one atrium-ventricular septum defect (AVDS), and one open ductus arteriosus.
Five procedures were converted (27.7%): one in the child with type A esophageal atresia as there was just not enough space to do the duodenoduodenostomy due to the hugely distend stomach and proximal duodenum, one because of the associated malrotation, one because the distal part of the web appeared difficult to find de-spite longitudinal duodenotomy, one for convenience, and one in the child with jejunal atresia for the tapering of the proximal bowel and subsequent anastomosis.
Thirteen procedures were laparoscopically com-pleted, but four leaked. Two had associated esophageal atresia repaired thoracoscopically during the same general anesthesia, one had total colonic aganglionosis and iatrogenic perforation of the colon, and one has associated malrotation. In the 1-year-old child with duodenal stenosis, reoperation was required because of recurrent stenosis most likely due to overenthusias-tic use of electrocautery for making the enterotomies.
We realize that we have had a high complication rate. Fortunately none of the children died. Duodenal
atresia and stenosis as well as jejunal atresia is un-doubtedly a difficult field to be treated by endoscopic surgery. The working space is very limited, a hand sewn anastomosis has to be made, there is often associ-ated pathology in the gastrointestinal tract and outside, for example malrotation, esophageal atresia, and car-diac malformations, and half of the children in our se-ries had trisomy 21. The fact that only a few publica-tions have been published regarding this topic seems to support the difficulty of endoscopic correction (Bax and van der Zee 2001; Gluer et al. 2002; Nakajima et al. 2003; Rothenberg 2002; Steyaert et al. 2003). We have decided to do endoscopic repairs of this type of pathol-ogy only when at least two experienced endoscopic pediatric surgeons are available to do the operation to-gether.
Discussion
Although indications for endoscopic pediatric surgery continue to expand, the laparoscopic repair of duode-nal atresia/stenosis in our series has not been without complications. Therefore reflection on the conse-quences and complications is warranted. A low con-version threshold should be adopted.
As far as jejunal atresia is concerned, laparoscopy may be of help in determining the exact anatomy and in the correction of a concomitant malrotation, allow-ing for a very small laparotomy to finish the operation. For tapering of the dilated part of the jejunum and sub-sequent anastomosis, a laparoscopically assisted ap-proach seems the most achievable at the present time.
References
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