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16 Robotic System Assisted Soave Procedure for Hirschsprung Disease
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115
16.6 Technical Points andSkills
1. The trendelenburg position with slight right
tilt can keep the small intestine away from the
operation area.
2. The position of the cannula shall be adjusted
according to the range of the lesion and the
patient’s body shape. The ports shall be placed
in the lateral abdomen as far as possible to
avoid interference between the arms.
3. The broad sigmoid colon mesentery is suitable for the initiation of colon separation.
4. The marginal artery shall be preserved when
isolating the proximal colon by dissecting
close to the root of the mesentery.
5. Distal colon and rectum dissection should
close the bowel wall to avoid damaging the
pelvic nerves.
6. Blunt and sharp separation of the rectal sheath
in the submucosa can reduce bleeding.
7. Preserving the short muscle sheath of 3–5cm
in the anterior wall and 1cm in the posterior
wall and V-shaped resection in the posterior
wall can reduce the complications of myosheath inammation and myosheath stenosis.
8. When performing proximal colon pullthrough, it is necessary to identify the order of
the colon to avoid twisting.
9. Attention should be paid to avoid damaging
the ureters, vas deferens, iliac vessels, ovaries,
or testicular vessels.
16.7 Postoperative Complications
Although most children with HSCR recover
smoothly after surgery, postoperative complications
still conict with a signicant proportion of patients,
especially constipation and fecal soiling. Anal dilatation is mandatory 2 weeks postoperatively and
lasts for 3–6 months, and the patient should be
closely followed up until adulthood [5–8].
1. Bleeding. Mostly cases occur within 24hours
after the operation and are commonly caused
by electrocoagulation eschar shedding or
retraction of the dissected mesenteric vessels.
Mesenteric vessels should be handled carefully during the operation and ligated or
clamped when necessary. The wound should
be checked for bleeding before the end of the
operation.
2. Anastomotic stenosis. The colon is pulled out
through the rectal muscle sheath in the Soave
procedure, and the rectal muscular cuff is
prone to compressing and narrowing the
colon. An oblique anastomosis, a short muscle sheath with a “V” shape resection in the
posterior wall may alleviate the occurrence of
stenosis. Anal dilatation is suggested routinely from twoweeks after the operation.
3. Anastomotic leakage. Poor blood supply or
excessive tension can lead to postoperative
colon ischemia, necrosis, and anastomotic
dehiscence. Ensuring good blood supply and
without tension when pulling-through the
proximal colon, removing fat and surrounding
connective tissue can ensure good healing of
the anastomosis.
4. Enterocolitis. The incidence of HD complicated enterocolitis accounts for 10% - 18%
and can occur perioperatively or postoperatively, especially in those who have enterocolitis before surgery, which is more likely to
occur after surgery. Colorectal outlet obstruction, damage to the bowel mucosal barrier,
and intestinal immune function are the main
causes of enterocolitis.
5. Fecal soiling. Sphincter injury during pullthrough results in abnormal sphincter function. Anastomosis below the dentate line may
cause loss of the transitional epithelium and
abnormal sensation. Both will lead to the
occurrence of fecal soiling.
6. Constipation. Anastomosis stenosis or rectal
cuff restriction, residual aganglionic bowel or
excessively dilated colon, recurrent enterocolitis, concomitant variant HD, and internal
sphincter achalasia are possible causes of constipation. Treatment should be selected
according to the cause of constipation, and
reoperation is necessary in some cases.
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16.8 Comparison withTraditional
Laparoscopic Surgery
The essential of robotic system assisted Soave
procedure is laparoscopic approaches with the
upgrading of instruments and equipment. The
indication is similar to that of laparoscopic surgery, but there are also differences in the application principle.
1. The three-dimensional camera with features
of high-magnication and higher resolution
can ensure clearer surgical eld vision and
more accurate manipulation.
2. The EndoWrist® instruments simulate a sur-
geon’s hand and wrist movements, with seven
degrees of freedom and tremor cancelation,
making them more suitable in narrow spaces,
especially for low rectal dissection in the pelvic cavity of HSCR patients.
3. The camera is controlled by the surgeon him-
self/herself, and it can be timely and accurately
adjusted according to the manipulator’s intention, truly achieving hand-eye coordination.
4. Although the arms of the robotic system
occupy a certain space, the distance between
the canula is slightly longer than that of conventional laparoscopy. By reasonably distributing the operating ports, newborns weighing
more than 5kg can be well operated under the
robotic system as well.
5. Robot-assisted surgery is more difcult for
long-segment or total colonic aganglionosis,
and the surgical eld of vision needs to be
constantly changed. The system needs to
docking repeatedly, thus inevitably increasing
the operation time.
6. Robotic surgery lacks tactile feedback and
needs visual compensation. It is difcult for
green hands to accurately control their
strength, and tissue tears, intestinal injuries,
or suture fractures frequently result.
7. The robotic approach is more expensive than
laparoscopic surgery, and special instruments
are still lacking for children. We look forward
to new instrumentations and new products
entering the market will lower the prices,
making the technology more available for
ordinary patients.
8. Finally, robot-assisted surgery may increase
surgical time. At present, skilled operators can
control the docking time within 5–10 min
without signicantly prolonging the operation
time, and the total operation time is even
shorter than that of conventional laparoscopic
surgery because of the convenience of intraoperative operation.
References
1. Mueller JL, Goldstein AM. The science of
Hirschsprung disease: What we know and where we
are headed. Semin Pediatr Surg. 2022;31:151157.
2. Hebra A, Smith VA, Lesher AP. Robotic Swenson
pull-through for Hirschsprung's disease in infants. Am
Surg. 2011;77:937–41.
3. Pini Prato A, Arnoldi R, Dusio MP, etal. Totally robotic
soave pull-through procedure for Hirschsprung's disease: lessons learned from 11 consecutive pediatric
patients. Pediatr Surg Int. 2020;36:209–18.
4. Pini Prato A, Arnoldi R, Faticato MG, et al.
Minimally invasive redo pull-Throughs in
Hirschsprung disease. J Laparoendosc Adv Surg
Tech A. 2020;30:1023–8.
5. Quynh TA, Hien PD, Du LQ, etal. The follow-up of the
robotic-assisted soave procedure for Hirschsprung's
disease in children. J Robot Surg. 2021;16:301.
6. Delgado-Miguel C, Camps JI. Robotic soave pull-
through procedure for Hirschsprung's disease in children under 12-months: long-term outcomes. Pediatr
Surg Int. 2021;38:51.
7. Rintala RJ, Pakarinen MP. Long-term outcomes
of Hirschsprung's disease. Semin Pediatr Surg.
2012;21:336–43.
8. Meinds RJ, van der Steeg AFW, Sloots CEJ, et al.
Long-term functional outcomes and quality of life
in patients with Hirschsprung's disease. Br J Surg.
2019;106:499–507.
Robotic-Assisted Anorectoplasty
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for Congenital Anorectal
Malformation
JinfaTou andDengmingLai
17
17.1 Introduction
Congenital anorectal malformation (ARM) is a
common disease in the neonatal period. It is the
most common malformation of the digestive tract.
The incidence rate is (2–5)/10,000 and roughly
equal in boys and girls but slightly more in boys
[1, 2]. Its etiology and embryonic pathogenesis
are not yet clear. There are many types of ARM,
ranging from the mildest membranous anus to
severe cloaca deformities. The International
Classication of Windspread proposed in 1984
divided ARM into low, median, and high based on
the position of the rectal blind end. For middle to
high ARMs, staged surgery is generally needed,
with colostomy in the rst stage and anorectoplasty in the second stage, including traditional
perineal anoplasty, and posterior sagittal anorectoplasty, With the development of laparoscopic
technology these children gradually adopted laparoscopic anorectoplasty (LARP) [3]. The blind
end of the rectum is freed in the pelvis through
laparoscopy. After the urethral stula is cut and
ligated, the blind end of the rectum is dragged out
through the center of the sphincter. LARP can
reduce the damage to the surrounding tissues and
pelvic nerves, and improve the outcome. Robotic
surgery can perform more delicate operations and
reduce the damage [4].
17.2 Indications
andContraindications
17.2.1 Indications
Children with ARM need to undergo MR examination before surgery to exclude sacral tumors
and tethered spinal cord and to complete the distal colonography to determine the position of the
rectal blind end and stula. This operation is suitable for a rectal vesical stula, rectal-prostatic
stula, rectal urethral bulbar stula, high cloaca,
pouch colon (type IV), high rectovaginal stula,
high rectal atresia [5–8].
17.2.2 Contraindications
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_17.
J. Tou (*) · D. Lai
Department of Neonatal Surgery, Children’s Hospital,
Zhejiang University School of Medicine, Hangzhou,
China
e-mail: toujinfa@zju.edu.cn; dengming_lai@zju.edu.cn
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_17
1. The general condition is poor, the function of
important organs such as the heart and lungs
is poor, and the pneumoperitoneum cannot be
tolerated [9, 10].
2. Abdominal adhesions are severe, and there is
a lack of laparoscopic operation space.
3. The patients with sacral tumors or presacral
meningocele.
117
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J. Tou and D. Lai
17.3 Preoperative Preparation
1. The general condition of the patient should be
routinely assessed before the operation.
2. Routine distal colonography should be performed to conrm the position of the rectal
blind end and stula.
3. Routine preoperative preparation: preoperative fasting, gastrointestinal decompression,
distal colon cleaning enema, blood preparation, correction of severe anemia.
4. Surgical instruments: prepare 3 sets of robotic
puncture trocars, a 3 mm auxiliary trocar,
Debakey forceps, permanent cautery hook,
needle holder, 3 mm laparoscopic grasping
forceps, scissors, suction device, etc.
17.4 Position andDocking
17.4.1 Surgical Position
Adopt a supine position with the head, neck, and
trunk height 5-10 cm if patients’ body weight
under 3 kg.
17.4.2 Layout ofOperation Hole
1. The observation hole (No. 2 arm) is located at
the umbilicus (Fig. 17.1);
Fig. 17.1 Position of Troca.
2. The operation hole 1 (No. 1 arm) is located at
the at umbilicus of the left anterior axillary
abdomen;
3. Operation hole 2 (No. 3 arm) is located at the
at umbilicus of the anterior axillary line of
the right abdomen;
4. The auxiliary operation hole (assistant hole) is
located behind the midpoint of the connection
line between the observation hole and operation hole 2, as far as possible from the operation area.
17.5 Surgical Procedures
1. Preparation for surgery position: Adopt a
supine position, with feet high and head low
tilted approximately 30°.
2. The positioning layout of the operating hole.
Due to the small volume of the small infants
abdominal cavity, in principle, the distance
between the operating area and the casing should
be as large as possible, and the operating instruments should not interfere with each other.
3. Routine disinfection and draping: the surgical
nurse prepares the robot operating arm for
aseptic bagging.
4. Establishment of pneumoperitoneum and
placement of the cannula. The umbilical incision is cut 8mm, the pneumoperitoneum needle is punctured to establish the
pneumoperitoneum (pressure 6–8mmHg), and
the rst 8mm cannula is inserted into the main
sight glass. The second 8 mm cannula was
placed at the at umbilicus of the anterior axillary line of the left abdomen, and the operating
forceps were inserted. The third 8mm cannula
is placed at the at umbilicus of the anterior
axillary line on the right side of the abdomen,
as the main operating hole, and the permanent
cautery hook is inserted. The fourth 3 mm
sleeve is placed behind the midpoint of the connection between the observation hole and operating hole 2, as far away as possible from the
operating hole, as an auxiliary operating hole,
used for traction exposure, suction, scissors,
and needle and thread in and out operations.
5. Routinely suspend the bladder wall through
abdominal wall traction to increase the pelvic
operation space.
DEF
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119
Fig. 17.2 (a) Suspend the top of the bladder to increase
the pelvic space; (b) The rectum was ligated near the stula to facilitate traction, reduce the overow of intestinal
Fig. 17.3 Suture of the stula
6. Exploring the position, shape and surrounding
tissues of the blind end of the rectum, in the
pelvic cavity along the rectal wall, gradually
coagulate the mesoderm until the peritoneum
reexes, pay attention to protect the bilateral
ureters, vas deferens, and other surrounding tissues, and ligate the intestines. After opening
the peritoneal reection, continue to move
downward along the intestinal wall until the
stula is completely exposed (Fig. 17.2). The
anterior wall of the stula was cut to determine
the diameter of the stula. The stula can be
completely cut off after a 5-0 absorbable gure-eight suture. The pelvic cavity is ushed,
and the blind end of the rectum is ready for use
(Fig. 17.3). The lithotomy position was
changed to determine the position of the anal
points, gradually expanding along the center of
the sphincter into the pelvic cavity, dragging
the blind end of the rectum out, and anastomosing with the anus [11].
contents and pollute the pelvic cavity when the stula was
opened; (c) The stula is completely exposed
17.6 Technical Points andSkills
1. The volume of the abdominal cavity of the newborn is small, and the distance between the
operation holes is limited. When arranging the
holes, try to choose the largest distance, to avoid
mutual interference of the mechanical arms.
2. When freeing the blind end of the rectum, try to
be as close to the intestinal wall as possible to
reduce the damage of the surrounding tissues.
3. The neonatal intestine tissue is fragile, so it
needs to be lifted more gently.
4. After the rectum is pulled out, proper tension
is maintained to avoid blood supply obstacles.
5. When treating rectal-prostatic stula or rectalurethral bulbar stula, it is more difcult to
expose the posterior wall. choosing to ip the
lens eld of view, it can be displayed more
clearly.
6. If the stula is completely cut off, the distal
end of the stula tissue tends to retract, and it
is difcult to expose. After the stula is fully
freed, the anterior wall is opened rst, and part
of the posterior wall is retained for traction,
which is helpful for suturing the stula (Fig.
17.3).
7. Techniques for the muscular tunnel: Through a
muscle stimulator, the outer orice of the muscular tunnel is clearly dened. A small incision
was made and separated along the two sides of
the contraction center with forceps under
direct vision and gradually expanded into the
pelvic cavity. The endoscope observed the tip
of the forceps pulling through the triangle
formed by the back of the stula and the two
sides of the pubococcygeal muscle belly,
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J. Tou and D. Lai
ensuring that the tunnel was located in the center of the sphincter complex [4, 11, 12].
17.7 The Dierence Between
Robotic Analplasty and
Traditional Laparoscopic
Analplasty
The essence of robotic anoplasty is laparoscopic
anoplasty with upgraded instruments and equipment. The principles and steps of the operation
are the same [11].
17.7.1 Advantages
The robot’s three-dimensional eld of vision is
clearer, and it is a heat source, which can maintain the clarity of the lens for a long time without
being affected by smoke, etc., which guarantees a
smooth operation process.
The highly exible robotic arm system of the
robot can complete difcult operations such as
grasping, holding, walking, hemostasis, suturing,
and ligation in a small space and can easily suture
deep pelvic stulas. At the same time, it reduces
the fatigue of the surgeon and reduces
misoperation.
The learning curve of the robotic system for
difcult surgery is signicantly lower than that of
traditional laparoscopic surgery, and doctors with
a certain amount of laparoscopic surgery experience can quickly adapt to the operation.
For the operation in limited space of the low
pelvic cavity, the robot is more fully exposed.
17.7.2 Limitations
The robotic arm of the robotic system will occupy
a certain amount of space, and the assistant hole
position selection and operation space will be
more limited than traditional laparoscopy.
Especially when the location of the stula is
poorly selected, it affects the layout of the robot’s
operating holes.
The operation cost of the robot system and the
use of equipment are higher than those of traditional laparoscopes, which will increase medical
costs.
17.8 Complications and
Prevention
17.8.1 Intraoperative Complications
1. Paracentesis injury: In children, the abdominal space is limited, and there is a history of
colostomy that leads to adhesion. When establishing a pneumoperitoneum or puncturing,
the intra-abdominal blood vessels or organs
may be injured accidentally. Due to the limited abdominal space, the rst trocar can be
placed under direct vision. After the pneumoperitoneum is established, other trocars can be
placed under laparoscopic monitoring. Once
blood vessels or organs are injured, repair is
needed rapidly [11, 12].
2. Pneumoperitoneum-related complications:
The high diffusion of CO2 in the peritoneum of
infants or newborns can easily lead to hypercapnia and heart or lung dysfunction. Reduced
pressure of pneumoperitoneum and shortened
operation time monitoring blood gas and endexpiratory PCO2 during the operation are helpful for prevention. Suspending the operation or
pneumoperitoneum can reverse dysfunction,
the operation can be recovered within a short
time. Once the vital signs are unstable, robotic
anorectoplasty should be transferred to an
open procedure [13, 14].
3. Intraoperative hemorrhage: With robotassisted operation, mesangial blood vessels
are clearly exposed. Some children are likely
to bleed due to repeated inammation and
adhesion near the stula, especially in the
pouch colon. Bipolar coagulation or coagulation scissors are recommended when freeing
the rectal wall. Bleeding is always reduced
after cutting the stula, and pelvic drainage is
placed when necessary.
4. Urethra and ureter injury: Urethral and ureteral injuries rarely occur due to clear tissue
17 Robotic-Assisted Anorectoplasty for Congenital Anorectal Malformation
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121
exposure under robot assistance. Urethral
injury may occur when freeing the low stula,
and the urinary catheter reserved for 1 week
after the operation is an effective treatment.
Once the ureter injury is conrmed, a repair
operation is needed [15–17].
5. Vas deferens injury: This may occur when
freeing the rectal urethral bulb stula. Once
injured, both ends of the injury should be
trimmed, aligned and then sutured with 6-0
absorption thread.
17.8.2 Postoperative Complications
1. Postoperative bleeding: Supplementing prothrombin, plasma, and brinogen is effective
for treating pelvic wound bleeding. Massive
hemorrhage of mesangial blood vessels
requires another operation. Pelvic muscular
tunnel bleeding is rare. Compression of the
rectum is always effective for most bleeding.
Otherwise, disassembling the anastomosis,
nding the bleeding point and suturing the
bleeding are also helpful.
2. Urethral diverticulum: Insufcient separation
and resection of the rectal-urethral stula may
cause urethral diverticulum. Once this occurs,
another endoscopic operation can be performed to remove the diverticulum and repair
the urethral stula [18].
3. Urinary retention: Pelvic nerve injury is
caused when freeing the rectum. Indwelling
urinary catheters and nerve nutritional treatment are required for recovery [13].
4. Wound infection and rectal retraction are
related to insufcient loosening of the proximal bowel tube, excessive anastomotic tension, poor rectal blood supply, distal rectal
necrosis, severe local infections, or detached
sutures. Once it occurs, surgical treatment is
needed.
5. Anal stenosis: After anorectoplasty, anal
expansion is needed. High-position deformity,
due to the long muscular tunnel, especially
requires regular anal expansion. Poor blood
supply to the distal rectum, anastomotic infection, and irregular anal expansion can lead to
anal stenosis. The prevention treatment is
expanding anus. If the rectal mucosa is atrophied and degenerated and anal expansion is
ineffective, it is necessary to resect the narrow
segment and anastomosis again.
6. Rectal prolapse: Too much free rectum in the
pelvic cavity leads to less tension when the
rectum is pulled through. Prolapse of one side
of the mucosa is usually caused by the deviation of the tunnel position and the asymmetry
of the muscles. Resecting the prolapsed bowel
is also needed.
7. Fecal incontinence: High-position malformations are often related to sphincter dysplasia.
Diet therapy and biofeedback therapy are
used, and some get better gradually without
treatment. Without improvement, effective
bowel management is needed. If the MR
examination reveals that the rectum has not
passed through the sphincter complex, another
surgical treatment is needed [13].
8. Constipation rarely occurs in high-position
ARM, but due to laparoscopic or robotic surgery, the rectum is pulled through the muscular tunnel, and the incidence of constipation is
higher than that of traditional open surgery. It
is related to the preservation of the dilated
colon and the narrowing of the tunnel scar.
Generally, conservative treatment is rst performed, such as anal expansion, defecation
training, laxatives, enema, and biofeedback
treatment. If it causes megarectum or secondary megacolon, surgical treatment is needed
[19, 20].
References
1. Cuschieri A.Descriptive epidemiology of isolated anal
anomalies: a survey of 4.6 million births in Europe.
Am J Med Genet. 2001;103:207–15.
2. Pena A, Levitt MA.Imperforate anus and cloacal malformations. In: Ashcraft K, Holcomb II GW, Murphy
JP, editors. Ashcraft’s pediatric surgery. Philadelphia:
Saunders Elsevier; 2010.
3. Holschneider A, Hutson J, Pena A, et al. Preliminary
report on the international conference for the development of standards for the treatment of anorectal malformations. J Pediatr Surg. 2005;40:1521–6.
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4. Albassam A, Gado A, Mallick MS, et al. Roboticassisted anorectal pull-through for anorectal malformations. J Pediatr Surg. 2011;46:1794–7.
5. Diao M, Li L, Ye M, et al. Single-incision laparoscopic-assisted anorectoplasty using conventional
instruments for children with anorectal malformations
and rectourethral or rectovesical stula. J Pediatr Surg.
2014;49:1689–94.
6. Bischoff A, Martinez-Leo B, Pena A. Laparoscopic
approach in the management of anorectal malformations. Pediatr Surg Int. 2015;31:431–7.
7. Diao M, Li L, Ye M, et al. Congenital anomaly rectied at birth: one-stage single-incision laparoscopicassisted anorectoplasty for newborns with anorectal
malformations and recto-urethral stula. Surg Endosc.
2016;30:5156–64.
8. Diao M, Li L, Kaoping G, et al. A novel laparoscopic technique for anorectal malformation
with low recto-bulbar stulae. Surg Endosc.
2017;31:4326–30.
9. Rentea Rebecca M, Halleran Devin R, Wood Richard
J, et al. The role of laparoscopy in anorectal malformations [J]. Eur J Pediatr Surg. 2020;30:156–63.
10. Mei D, Long L, An-Xiao M, et al. Efcacy of laparoscopic management of posterior urethral diverticulum in anorectal malformations [J]. Eur Urol.
2023;83:55–61.
11. Chang XP, Tang ST, Cao GQ, et al. Robotic-assisted
anorectal pull-through for anorectal malformations in 9 infants [J]. Chin J Minim Invasive Surg.
2018;18(6):549–53. https://doi.org/10.3969/j.
issn.1009-6604.2018.06.019.
12. Sawicka E.Evaluation of late results in the children
with anorectal anomalies [J]. Med Wieku Rozwoj.
2005;9(4):695–726.
13. Pakarinen MP, Rintala RJ.Management and outcome
of low anorectal malformations [J]. Pediatr Surg
Int. 2010;26(11):1057–63. https://doi.org/10.1007/
s00383-010-2697-z.
14. Chanchlani R, Budhwani KS. A study of the clinical prole and management of children with anorectal malformations [J]. Cureus. 2023;15(3):e36772.
https://doi.org/10.7759/cureus.36772.
15. Wang C, Diao M, Li L, et al. Laparoscopic dissection
and division of distal stula in boys with rectourethral
stula [J]. J Surg Res. 2017;211:147–53. https://doi.
org/10.1016/j.jss.2016.11.059.
16. Xiao H, Huang R, Cui X, et al. Single-incision laparoscopic versus conventional laparoscopic surgery
for rectobladderneck and rectoprostatic anorectal
malformations [J]. J Laparoendosc Adv Surg Tech
A. 2018;28(12):1553–7. https://doi.org/10.1089/
lap.2018.0260.
17. Cairo SB, Rothstein DH, Harmon CM. Minimally
invasive surgery in the management of anorectal malformations [J]. Clin Perinatol. 2017;44(4):819–34.
https://doi.org/10.1016/j.clp.2017.08.007.
18. Rentea RM, Halleran DR, Vilanova-Sanchez A,
et al. Diagnosis and management of a remnant of
the original stula (ROOF) in males following surgery for anorectal malformations [J]. J Pediatr Surg.
2019;54(10):1988–92. https://doi.org/10.1016/j.
jpedsurg.2019.02.006.
19. Pathak M, Saxena AK. Postoperative “complications” following laparoscopic-assisted anorectoplasty: a systematic review [J]. Pediatr Surg Int.
2020;36(11):1299–307. https://doi.org/10.1007/
s00383-020-04748-3.
20. Tainaka T, Uchida H, Tanaka Y, et al. Long-term outcomes and complications after laparoscopic-assisted
anorectoplasty vs. posterior sagittal anorectoplasty
for high- and intermediate-type anorectal malformation [J]. Pediatr Surg Int. 2018;34(10):1111–5.
https://doi.org/10.1007/s00383-018-4323-4.
Robotic-Assisted
https://t.me/medicina_free
Duodenoduodenostomy for
Duodenal Stenosis and Atresia
QingjiangChen andKenChen
18
18.1 Introduction
Duodenal stenosis and atresia are relatively rare
gastrointestinal malformations in neonates and
are common causes of duodenal obstruction,
with an incidence of 1/2500 – 1/10,000 live
births [1]. Surgery is the only curative treatment. In the past, laparotomy was mostly performed, and duodenal web resection and
duodenoplasty or duodenoduodenostomy were
selected according to the condition. In 2001,
Bax et al. [2] reported for the rst time the
application of laparoscopic surgery in the treatment of neonatal duodenal atresia. It has the
advantages of minimal invasiveness and rapid
recovery compared with traditional laparotomy.
With the rapid development and promotion of
laparoscopic techniques, an increasing number
of pediatric surgeons have selected laparoscopic
surgery for duodenal stenosis and atresia. With
the rapid popularization of laparoscopic techniques, robotic- assisted surgery systems have
further promoted the trend of minimally invasive and precise surgery with their more
advanced technical advantages [3]. Professor
John J.Meehan [4] reported the rst successful
cured case of a neonate with duodenal atresia
using the Da Vinci robot-assisted technique in
2007. In 2018, Andrea etal. [5] reported a case
of Da Vinci robotic-assisted duodenoplasty for
duodenal stenosis in an older child. Overall,
there are relatively few studies on roboticassisted duodenoduodenostomy for duodenal
stenosis and atresia. At present, some large
medical centers in China have introduced the da
Vinci robotic-assisted surgery system. In 2014,
the Da Vinci robotic surgical system was
updated and iterated to the fourth generation,
and the content of this section takes the da
Vinci® Xi system as the application equipment
for explanation.
18.2 Indications
andContraindications
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 981- 19- 9693- 1_18.
Q. Chen (*) · K. Chen
Department of General Surgery, Children’s Hospital
of Zhejiang University School of Medicine,
Hangzhou, China
e-mail: chengqj0157@zju.edu.cn; pwck@zju.edu.cn
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
Q. Shu (ed.), Pediatric Robotic Surgery, https://doi.org/10.1007/978-981-19-9693-1_18
Indications:
1. Duodenal septal stenosis: Da Vinci robotic
assisted partial web resection with HeinekeMikulicz–type duodenoplasty.
2. Duodenal atresia: Da Vinci robotic assisted
side-to-side duodenoduodenostomy, diamondshaped duodenoduodenostomy.
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Q. Chen and K. Chen
Contraindications:
1. Patients with unstable vital signs;
2. Premature infants or low birth weight infants
who cannot tolerate pneumoperitoneum;
3. Severe deformity and cardiopulmonary
dysfunction;
4. Patients with a history of abdominal surgery
and severe adhesions in the surgical area.
The above contraindications will gradually
become relative contraindications with the
improvement of surgeon technique, accumulation of experience, and upgrading of equipment.
For children with the above relative contraindications, the surgical team (including the surgeon,
surgical assistant, device and circulating nurse,
anesthesiologist, physician in the intensive care
unit, etc.) should organize a discussion before the
operation and conduct a comprehensive evaluation from the aspects of cardiopulmonary function tolerance, nutrition and internal environment
of the child, degree of abdominal adhesion, technical level of the surgical team, factors that may
lead to conversion to laparotomy, family economic conditions of the child, family wishes, and
efcacy expectations, to formulate a surgical
plan.
electrolyte abnormalities should be corrected
according to the results of blood gas
analysis.
3. Preoperative routine preparation included preoperative bowel preparation, patient communication, indwelling catheterization, blood
preparation and preoperative antibiotic
administration. Bowel preparation included
fasting of a solid diet for 8 hours and clear
drinking for 2 hours before surgery, preoperative gastrointestinal decompression, and
saline enema to reduce intraoperative bowel
atulence and to avoid interfering with the
visual eld. The contents of patient communication, including preoperative conversation
between doctors and patients and preoperative
education of nursing, enable the guardians to
fully understand the process of surgery, possible complications, and perioperative matters
and relieve the psychological pressure of family members and children. Blood and plasma
preparation and antibiotic administration are
routinely needed.
18.4 Position andDocking
18.4.1 Patient Position
18.3 Preoperative Preparation
Preoperative preparation for robotic-assisted surgery for duodenal stenosis and atresia includes
the following:
1. Preoperative imaging examination included
color Doppler ultrasound, abdominal radiography, upper gastrointestinal series, and gastroscopy to understand the location and nature
of the obstruction, develop the corresponding
surgical plan, fully assess the possible risks
and deal measures.
2. Preoperative physiological and internal environment evaluation: included nutritional status evaluation and intravenous nutrition
support for patients with severe malnutrition.
In severe cases of anemia, preoperative blood
transfusion is needed. Maintaining homeostasis is necessary, and uid imbalance and
The patient was placed in a supine position. The
operative bed was placed in a reserve
Trendelenburg position with a slight left tilt to
facilitate exposure of the surgical eld.
18.4.2 Cannula Placement
The second part of the duodenum is considered
the “target” organ for duodenoduodenostomy.
The camera port (No. 3 port in Fig. 18.1) is
placed at the umbilicus.
• R1 (port 2 in Fig.18.1) is placed in the right
lower quadrant for the bipolar grasper.
• R2 (port 4 in Fig. 18.1) is placed in the left
upper quadrant for robotic monopolar hook/
scissors, harmonic scalpel and/or Ligasure.
• An assistant port (port 5 in Fig. 1) is arranged
behind port 3 and port 4 for grasping forceps,
scissors or aspirators when necessary.
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