From
StayCurrentMD
Technique: Laparoscopic Repair of Duodenal Atresia, Ladd's Procedure, and...
With Dr. Steve Rothenberg
Part of
Malrotation 7 items
Chapter 1 of 4 · Surgical Management
Setup & ports
Room Setup, Port Placement, and Initial Exposure
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
The patient is a 1 day old infant who had a prenatal diagnosis of duodenal atresia
Room setup places baby at foot of table with surgeon standing at baby's legs for most ergonomic position
Port placement: 4mm scope in umbilicus, 3mm port in left mid quadrant, 3mm stab wound in right mid quadrant, triangulated towards right upper quadrant
The 3 millimeter sealer is an excellent dissecting device and can be used in safe energy in close approximation to both the gallbladder and the small bowel
A transabdominal stitch (30 Prolene on RB1 needle) placed through anterior abdominal wall in right upper quadrant retracts gallbladder superiorly for greater exposure
The child has malrotation with complete duodenal atresia
The sealer is an excellent instrument for grasping and manipulating the bowel in an atraumatic fashion
A Meckel's diverticulum was found in the distal ileum during the procedure
All small bowel is placed on patient's right and large bowel on patient's left during Ladd's procedure
Widening the mesenteric base should diminish the chance of volvulus in the future
Transverse enterotomy is made at the most dependent portion of the dilated proximal segment
The distal segment enterotomy is longitudinal
There is increased smoke and debris from using electrocautery compared to the 3mm sealer
A transabdominal stitch aligns the two sides of bowel to perform the side-to-side anastomosis and makes it quite easy
Pre-cut Vicryl suture approximately 10 to 12 centimeters in length is used to run the back row of the anastomosis
In some cases the distal duodenal segment is more fixed to the retroperitoneum making this part of the procedure more difficult, but the same technique is used with excellent result
This portion of the anastomosis can be done in an interrupted fashion, but a running suture works extremely well and is more efficient
The entire procedure took approximately 50 minutes
The patient was a 2.8 kg child
About 10% of patients who undergo laparoscopic repair of duodenal atresia have malrotation
A nasogastric tube is left to suction for approximately 3 to 4 days; in most cases feeds are started by the 5th day
This child started eating on the 5th postoperative day and was on full feeds by the 8th postoperative day
The base of the Meckel's could adequately be divided without compromising the lumen of the bowel, so decision was made to remove it using 5mm stapler
The 3mm port in left quadrant was changed to 5mm port to allow insertion of endoscopic stapler
The base of the Meckel's was crushed with an atraumatic clamp before stapler was applied
Because of the malrotation, the appendix was also removed
The child was discharged to home on the 10th postoperative day