laparoscopic management of small intestinal atresia george w. holcomb, iii, m.d., mba children’s...

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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