Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome (13...

This is a 13-year-old male who presented with acute epigastric pain and bilious emesis. He had no history of weight loss or surgical procedures and was at the 50th percentile for weight given his age. A CT scan demonstrated an obstruction at the third portion of the duodenum and a narrow aorta mesenteric angle. An NG tube was placed for decompression and a nasoduodenal tube placed for feeds. After failing to gain weight over a two-week period and ongoing high volume NG tube output, the patient was taken to the operating room for bypass. A laparoscopic duodenojejunostomy was performed using an umbilical camera port, a right-sided retracting port, and two left-sided working ports. The transverse colon was retracted superiorly to reveal the 3rd portion of the duodenum, superior mesenteric artery, and inferior vena cava. A transabdominal suture through the omentum was used to retract the transverse colon during the dissection. The retroperitoneum overlying the third portion of the duodenum was opened sharply, and the duodenum was mobilized. An anastomosis at this location has the benefits of leaving the transverse music colon intact and avoids a duodenal diverticulum proximal to the mesenteric root. The ligament of trites was identified, and a lupirogenum approximately 30 centimeters distal to the ligament was selected. The epharynogenal limb and duodenum were aligned with a suture to facilitate the anastomosis. Enterotomies were made to allow passage of a 45 millimeter endoGIA stapler, and the stapler was fired. An additional traction suture was placed at the level of the resulting common enterotomy to facilitate exposure and subsequent closure. The anastomosis was inspected for hemostasis. And the common enterotomy was closed with an absorbable suture in a single layer. Postoperatively, the patient underwent bowel rest for 5 days, at which time a contrast study was performed, demonstrating a patent anastomosis without leak. The patient's diet was quickly advanced, and he was discharged 2 days later.