Authors: Rosie Cresner; Carmen Sofia Chacon; Simon Clarke, MR; Chelsea and Westminster Children's Hospital, London
We present a step-by-step demonstration technique of a robotic duodenal enterotomy and polypectomy. The patient was a 7y old girl with known background of Peutz Jeger’s Syndrome who presented via clinic with intermittent upper abdominal pain and non-bilious vomiting. She was dehydrated and acidotic pre-operatively due to profuse vomiting. A D1 duodenal polyp causing obstruction was seen on duodenoscopy. The base was 2.5 cm and too large to snare endoscopically. We performed a robotic enterotomy and polypectomy. 3 robotic,1 balloon accessory ports and a liver retractor were placed. The robot allowed much easier manipulation of the duodenum, retrieval and eversion of the polyp from within the lumen, and allowed easy closure of the enterotomy with 2 layer running suture. The patient had excellent uneventful recovery with reintroduction of enteral fluids 48h after the surgery and discharge on the forth post-operative day. This technique should be considered for further cases.
Presenter: Rosie Cresner
rosiecresner@gmail.com
Intended audience: Healthcare professionals and clinicians.
Patients with Putzjogers have hamatomatous polyps that are most commonly in the small bowel. They can present to us in a number of ways, including with symptoms of intestinal obstruction. Historical data has shown that 68% of patients with Peutzjoger's have undergone a laparotomy for interception by the age of 18 years. We were referred a 7-year-old girl with known Peutzjagers who was symptomatic of a daily profuse vomiting. Previous upper GI endoscopy had identified a large duodenal polyp filling the lumen of the bowel. We elected to perform a robotic enterotomy and polypectomy in order to employ a minimally invasive approach to be able to operate at what was likely to be an awkward angle near the duodenum and for better dexterity in closing the enterotomy. Using the da Vinci robot at our center, we had two robotic instrument ports, 1 accessory port, and a Nathanson retractor. The bulging duodenum could be seen, and the enterotomy was made using hook diathermy. The polyp could be seen, and is averted. You can see how much polyp is filling the lumen, it's delicate unhandling, and the mucosa bleeds easily. You can see the polyp is on a stalk, but it is quite wide. The stalk is endo leaped. And the polyp is removed via an endo bag. Closure of the enterotomy is achieved with PDS in a continuous double layer closure. Skin to skin time was 90 minutes. The patient made an uneventful recovery, was kept nil by mouth for 48 hours, and then progressed to a normal diet and was discharged on the 4th postoperative day. Histology was consistent with a hematomatous polyp. There is no consensus on surveillance strategies in the pediatric population of patients with Puzoger's and a paucity of evidence. Any surveillance program, there needs to be a balance between preventing complications of disease and overinvestigation and their associated complications. FScan recommends commencing surveillance at 8 years of age or earlier if symptoms are reported, using upper and lower GI endoscopy and video capsule endoscopy. This should be repeated every 3 years. In our literature review, this is the first robotic duodenal polypectomy in the pediatric population described. And we hope you will agree this provides a valid approach for consideration in the future.
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