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Laparoscopic Management of Small Intestinal Atresia
George W. Holcomb, III, M.D., MBAChildren’s Mercy Hospital
Kansas City, MO
Duodenal Atresia/Stenosis
• Most common site neonatal intestinal obstruction
• Associated with Trisomy 21 and annular pancreas
• Error in re-cannalization
• 50% will have another organ system anomaly
Duodenal Atresia/Stenosis
• Type 1 – 92%
intact mesentery; web b/w 2 segments
obstruction usually near ampulla
Duodenal Atresia/Stenosis
Diamond-shaped
duodenoduodenostomy
is the preferred
technique
Laparoscopic Approach
• Baby supine, foot of bed
• Suture around falciform
• Liver retraction
• Umbilical port – telescope/camera
• Working ports right side of abdomen
Laparoscopic Approach
Use regular cautery with fine tip needle
Laparoscopic Approach
U-clips (Medtronic) used for anastomosis
Laparoscopic Approach
Laparoscopic Duodenoduodenostomy
Concurrent Series2003 - 2006
• Retrospective study
• 28 babies – 14 open, 14 laparoscopic
• Open: 11 atresia, 3 stenoses
• Laparoscopic: 12 atresia, 2 stenoses
• No difference in age, weight, chromosomal anomalies, incidence of heart disease b/w 2 groups
AAP, 2007AAP, 2007
Concurrent Series2003 - 2006
AAP, 2007AAP, 2007
Open
(14)
Laparoscopic
(14)
P Value
Op Time (min) 96 116 0.09
Anastomotic Leaks 0 0 1.00
Initial Feed (days) 11.3 5.9 0.002*
Full Feed (days) 16.9 10.2 0.008*
Postoperative hospitalization (days)
20.1 13.0 0.008*
Conclusions
• Laparoscopic approach for duodenal atresia is safe and efficacious
• Patients undergoing the laparoscopic approach had more rapid advancement of feedings and shorter hospitalization
• Use of the U-clips allows for a faster operation if an interrupted suture technique is preferred
Jejunoileal Atresia
• Due to late intrauterine mesenteric vascular accidents
• More common than duodenal atresia (1/1000 live births)
• Uncommon to have other anomalies
Jejunoileal Atresia
• Diagnosis usually evident
• More distal the obstruction, more distended loops of bowel
• Contrast enema usually helpful
Minimally Invasive Management
• Umbilical incision
• Extend if necessary
• Exteriorize bowel
Minimally Invasive Management
• Extracorporeal anastomosis
• RLQ or RUQ incision, if necessary
? ? Questions ? ?
www.cmhcenterforminimallyinvasivesurgery.com