Technique: Laparoscopic Repair of Duodenal Atresia, Ladd's Procedure, and...

This video demonstrates a laparoscopic repair of a duodenal atresia and malrotation in a patient. With an associated Meckel's diverticulum. The patient is a 1 day old infant who had a prenatal diagnosis of duodenal atresia. Here you see the room set up with the baby at the foot of the table and the surgeon standing at the baby's legs. This allows for the most ergonomic position. Here are the port placements a 4 millimeter scope in the umbilicus, a 3 millimeter port in the left mid quadrant, and a 3 millimeter stab wound in the right mid quadrant. Things are triangulated towards the right upper quadrant. Here you see the dilated. Proximal duodenum. Adhesions, which turn out to be lads bands are taken down using the 3 millimeter sealer. The gallbladder is also attached to these adhesions, and it is mobilized to allow for placement of a transabdominal stitch which will retract the gallbladder and the liver up out of the way. You can see that the 3 millimeter sealer is an excellent dissecting device and can also be used in safe energy in close approximation to both the gallbladder and the small bowel. The gallbladder completely mobilized. A transabdominal stitch, in this case a 30 prole on an RV1 needle, is placed through the anterior abdominal wall in the right upper quadrant and then used to retract the gallbladder superiorly, giving greater exposure to the area of dissection. With this done, it becomes apparent the child is now rotated. The distal duodenal segment is identified. And the complete atresia is found. Because of the malrotation, the bow is now run from proximal to distally to ensure that there are no further lad spans. And to completely de-rotate the bow. The sealer is an excellent instrument for grasping and manipulating the valve in an atraumatic fashion. During this portion of the procedure, a Meckel's diverticulum is found in the distal ileum. This will be addressed later. The valve is run until the ileocecal valve is identified. As seen here. All of the small bowel is placed on the patient's right and the large bowel on the patient's left. At this point, it can be seen that the. Mes face of the mesentery is widened. This should diminish the chance of volulus in the future. This completed, an enterotomy is made in the proximal dilated portion. Bow is entered using a 3 millimeter hook. And then the enterotomy is enlarged using. 3 millimeter hook scissors. This is a transverse enterotomy at the most dependent portion of the dilated proximal segment. And neurotomy is then made. In the distal segment And this is longitudinal. Again, the enterotomy is. Enlarged using the 3 millimeter hook scissors. One can note the increased smoke and debris that comes from using uh electrocautery in this case. Uh, which is not an issue during the use of the 3 millimeter here. With the otomies made, a transabdominal stitch is placed which aligns the two sides of the bowel to perform the side to side anastomosis. The stitch. Makes it quite easy to perform. The anastomosis as it aligns the two segments. For sutra. Now a pre-cut hoo viral suture is passed through the anterior abdominal wall, and it's used to perform the anastomosis. The back row is sewn first. The two ends are aligned at the apex. In the stitch, which is approximately. 10 to 12 centimeters in length. It's um Used to run the back row. Surgeon can follow themselves. This allows for alignment. The two sides of the bow with each stitch. Because of the malrotation present in this case. The two ends of the bowel are easily. Visualized and sung together. In some cases, the disco. Duodenal segment is more fixed to the retroperitoneum. Making this part of the procedure a bit more difficult, but the same technique is used with excellent result. The surgeon prefers, uh, this portion of the anastomosis can be done in an interrupted fashion. But we find that a running suture. Works extremely well and is more efficient. This is continued until the. Bottom of the anastomosis is reached. At this point, the stitch will be brought. From the inside out and rosal bits will be made. Which allows uh. For completion of the. Posterior row. Where you can see the posterior row being examined. And the slack of the suture being taken out. At this point, the stitch will be exteriorized. Uh, and the suture tied to itself. You see the external cirrhosis. This entire procedure to. Approximately 50 minutes. Here you see a 2nd stitch being placed. This will be now now be used to run the anterior. Again, the exposure is exceptional. In this uh. 2.8 kg child. Get up the surgeon Desires this can be done in an interrupted fashion. But we have found no problems using a running posterior wall and then a running anterior wall. We have found that about 10% of the patients that we perform laparoscopic repair of duodenal intrusion, Uh Now rotation. Again by using the. Tale of the future. The laxity of the right future can be. move And you can see the final bits being put in the anterior row. In general, we leave a nasal gastric tube dissuction for approximately 3 to 4 days. In most cases, by the 5th day, feeds are started. This child started eating on the 5th postoperative day. And it was on full feeds. By the 8th post-operative. Where the anastomosis is almost complete. The final stitch being placed. And then they Anterior running suture is. Sewing to the tail of the. Uh, posterior stitch. I mean, that's the monster is. There is the completed the nasty mon. The previously placed the. PDS suture, which was used to approximate the two. Sides of the bow. It's an uh. Tied as well to ensure that the apex of the anastomosis. You'll see. The stays featured through the advent of the gallbladder has been removed. And then the Meckel's diverticulum is addressed. Because, uh, it was felt that the uh. Base of the metals. Could adequately be divided without compromising the alum of the bowel. A decision was made to remove it using the 5 millimeter sta. Mesentery to the necklace was taken down with the sealer, and then the left quadrant, uh 3 millimeter port was changed to a 5 millimeter port. And the endoscopic staple was inserted. The base of the meals was crushed with an atraumatic clamp, and then the stapler was applied and the meal was resected. This was then removed through the 5 millimeter port. Because of the. Now rotation. The appendix was also removed, and this was treated in a similar fashion. Again, the entire procedure took 50 minutes. The child was started on feeds on the 5th postoperative day. Its on nearly full feeds. I did. 8th postoperative day. And was discharged to home on the 10th post method. Again, the base of the appendix is compressed within the a traumatic sealer. And then the staplers applied, completely resecting the.