Dr. Steven Rothenberg describes his technique for laparoscopic repair of jejunal atresia with apple peel defect. Key steps to the procedure include Veress entry, identification of the proximal and distal segments of jejunum, mobilization and resection of the short segment of dilated proximal jejunum with a laparoscopic stapler, a stapled end-to-side jejunojejunostomy, closure of the enterotomy, and decompression and retrieval of the specimen.
Type: video · 5 min · posted 2018-11-16 Canonical: https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751 ## Chapters - [0:00](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=0) Case presentation and operative setup - [1:30](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=90) Initial exploration and identification of apple peel defect - [3:00](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=180) Resection of dilated proximal segment - [4:30](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=270) Anastomosis creation and closure - [5:40](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=340) Postoperative course and outcomes ## Statements - "Newborn had prenatal diagnosis of bowel obstruction and was found to have jejunal atresia on upper GI study" (clinical) [0:00](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=0) - "Surgeon stands at baby's feet with cameraman on baby's right and scrub tech on patient's left" (clinical) [0:30](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=30) - "3-port technique used with 4mm 30-degree scope for visualization and two 3mm ports for dissection" (clinical) [0:50](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=50) - "Left mid quadrant port was later changed to 5mm for the stapler" (clinical) [1:10](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=70) - "Veress needle is inserted below the umbilicus to avoid injury to umbilical vessels and prevent CO2 embolism" (clinical) [1:20](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=80) - "Complete gap identified between proximal jejunum and distal bowel" (clinical) [2:00](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=120) - "Visualization of appendix and cecum suggests apple peel defect" (clinical) [2:20](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=140) - "Bowel twisting around mesentery confirmed apple peel defect" (clinical) [2:40](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=160) - "Because there was no evidence of kink or significant obstruction, mesentery was not further manipulated" (clinical) [3:00](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=180) - "Decision made to remove proximal dilated segment to improve bowel motility following surgery because it was relatively short and significantly dilated" (clinical) [3:20](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=200) - "3mm bipolar vessel sealer used to take down mesentery by clamping, sealing, and teasing vessels off mesenteric border of bowel" (clinical) [3:50](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=230) - "Dissection carried back almost to ligament of Treitz and encompassed approximately 10 cm length of bowel" (clinical) [4:10](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=250) - "5mm endoscopic stapler lays down 4 rows of staples and divides between them" (clinical) [4:30](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=270) - "Two applications of stapler required because bowel was so dilated with diameter almost 4 cm" (clinical) [4:45](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=285) - "Distal jejunal segment anastomosed to proximal dilated segment in end-to-side fashion" (clinical) [5:00](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=300) - "Enterotomy made in proximal dilated bowel using 3mm hook cautery and decompressed with 3mm sucker" (clinical) [5:15](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=315) - "Distal jejunal segment enterotomy slightly dilated to allow access of stapler" (clinical) [5:30](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=330) - "End-to-side anastomosis approximately 2.5 cm in length performed without difficulty" (clinical) [5:40](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=340) - "Resultant enterotomy closed with running bioabsorbable suture" (clinical) [5:55](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=355) - "Previous to having stapler, would have performed end-to-end anastomosis with multiple interrupted or running sutures" (clinical) [6:05](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=365) - "No evidence of significant mesenteric defect or gap in anatomy after enterotomy completion" (clinical) [6:20](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=380) - "Procedure took 80 minutes and was tolerated well by infant" (clinical) [6:35](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=395) - "Patient had diminishing NG aspirates over next week" (clinical) [6:50](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=410) - "Upper GI obtained one week postoperatively showed widely patent anastomosis" (clinical) [7:00](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=420) - "Resected specimen measured 10 cm" (clinical) [7:15](https://library.globalcastmd.com/watch/laparoscopic-jejunal-atresia-repair-technique-751?t=435) ## Transcript This video represents a laparoscopic intracorporeal repair of a duojunal atresia with an apple peel defect. A newborn who had a prenatal diagnosis of a bowel obstruction was found to have a jujunulatrijo upper GI. The patient was taken to the operating room and positioned on the field as shown. The surgeon stands at the baby's feet with the cameraman on the baby's right and the scrub tech on the patient's left. A 3 port technique was used with a 4 millimeter 30 degree scope for visualization and 23 millimeter ports for dissection. The left mid quadrant port was later changed to a 5 for the staple. The procedure is started by by infiltrating the infra umbilical ring and then making a small incision for insertion of the various needle. The various needle is inserted below the umbilicus to avoid injury to the umbilical vessels and prevent CO2 embolism. A 4 millimeter trochar is then inserted and the abdomen inflated. Here you see the transverse colon draped over what appears to be a very dilated proximal juju. The appendix is also visualized. Using 3 millimeter atraumatic bowel clamps, the proximal jejunum is examined and the resia identified. You can see there is a complete gap between the proximal jejunum and the distal valve. The appendix and cecum are visualized, suggesting that this is an apple peel defect. The bowel is then run from proximal to distal to ensure that there are no other areas of obstruction or kinking. As the bowel is run distally, it becomes very apparent that this is indeed an apple peel defect, as the bowel can be seen twisting around the mesentery. However, because there was no evidence of a kink or significant obstruction. The mesentery was not further manipulated. The bow was then run proximately to get to the distal jujunal segment. Which you've seen here. Because the. The proximal dilated segment was relatively short and it was significantly dilated. A decision was made to remove this to, in the hopes of improving the bowel motility uh following the surgery. The mesentery is taken, taken down using the 3 millimeter bipolar vessel sealer. Uh, here. As you can see, the vessels are. Clamped, sealed, and then teased off the mesenteric border of the bowel. This technique works quite well and is a traumatic. Once the proximal dilated bowel is adequately mobilized. It will be receptive. This dissection is carried back almost to the ligament of trites and encompasses approximately 0.10 centimeter length of bowel. With this done, the 3 millimeter port in the left mid quadrant is changed to a 5, and the 5 millimeter endoscopic stapler is inserted and used to divide the bowel. The stapler lays down 4 rows of staples and divides between them. In this case, the bow was so dilated that 2 applications of the staple were required. Uh, Diameter. Of the bowel in this area was almost 4 centimeters. With this done, It appears that the distal trijunal segment can be. Uh, anastomosis to the proximal dilated segment in an end to side fashion. An enterotomy is made in the proximal dilated valve using a 3 millimeter hook cautery. It is then decompressed with a 3 millimeter sucker. Similar otomy is then made in the distal jejunal segment. And this is slightly dilated in order to allow for access of the staple. The larger, larger anvil is placed in the neurotomy in the proximal bowel and the distal anvil is placed in the. Distal smaller renal segment. An end to side anastomosis is then performed without difficulty. This anastomosis is approximately 2.5 centimeters in length. The resultant otomy is then closed with a running rio viral suture. Previous to having the stapler, we would have performed an end to end anastomosis with multiple interrupted or running sutures. With the enterotomy completed. There is no evidence of this significant mesenteric defect. Or any gap in the anatomy. The large dilated resected segment is now decompressed. And it will be brought out through the 5 millimeter trocar set. Procedure took. 80 minutes and was tolerated well by the infant. Patient had diminishing NGE aspirates over the next week and an upper GI obtained on the. One week postoperatively showed a widely patent anastomosis. Here you can see the specimen being brought out through the trochar site. Again, it measured 10 centimeters. Here is the postoperative upper GI and here are the skin incisions immediately postoperatively and at 2 weeks. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai