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

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