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18 Robotic-Assisted Duodenoduodenostomy for Duodenal Stenosis and Atresia
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Fig. 18.1 Diagram of robotic port arrangement: ports 2, 3 and 4 are placed at the right lower quadrant, umbilicus and
left upper quadrant. An assisted port was placed behind port 3 and port 4
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18.4.3 Docking
After selecting the “upper abdominal operation”
mode, the EndoWrist arm 3 was connected with
port 3, the “targeting” button was pressed to
adjust the position of the robotic arms, arm 2 and
arm 4 were connected with port 2 and port 4, and
the operating devices were installed under endoscope monitoring. Thus far, the dorking procedure has been completed.
18.5 Surgical Steps
18.5.1 Surgical Procedures of
Robotic-Assisted Partial Web
Resection with HeinekeMikulicz-Type Duodenoplasty
1. After ports were placed and docking was n-
ished, gross exploration was performed to evaluate the degree of gastric and proximal duodenal
dilation and possible location of the diaphragm
and to rule out concomitant malformations,
such as malrotation and annular pancreas.
2. The falciform ligament of the liver is suspended to facilitate the exposure of the duodenum (Fig. 18.2a).
3. A Kocher maneuver is made to mobilize the
descending part of the duodenum to allow for
a tension-free anastomosis (Fig. 18.2b). The
ascending and transverse colon is mobilized
to the left when the duodenum is difcult to
expose.
4. The location of obstruction was identied as
the proximal dilated and distal collapsed
bowel. After a stay suture is placed at the
proximal end (Fig. 18.2c), a longitudinal incision is performed across the “transitional
zone”, and the duodenum is opened.
5. The duodenal web is identied and excised
from the duodenal wall, leaving a rim of tissue of 2–3 mm. The medial portion of the
membrane should remain intact to avoid damage to the ampulla of Vater (Fig. 18.2d).
6. The duodenum is then closed transversely
with interrupted anastomosis using 5-0
absorbable sutures. For older children, continuous suturing with 4-0 barbed sutures is
also a suitable choice.
126
DE
FG
HI
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Q. Chen and K. Chen
Fig. 18.2 (a) Suspension of the falciform liga-
ment of the liver; (b) mobilization of the duodenum; (c) suspension of duodenum; (d) resection of
duodenal septum; (e) transverse anastomosis of the
incision; (f) diamond -shaped anastomosis of the
incision
18 Robotic-Assisted Duodenoduodenostomy for Duodenal Stenosis and Atresia
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127
7. The abdominal cavity is irrigated with warm
saline, and drainage is not placed routinely.
The abdominal wall incision was closed.
18.5.2 Surgical Procedures of
Robotic-Assisted Duodenal
“Diamond-Shape”
Anastomosis
1. Steps 1, 2, and 3 are basically the same and are
not repeated.
2. A stay suture is made in the proximal end, and
the distal duodenum is sufciently isolated to
facilitate a tense free anastomosis. A transverse
incision is made in the proximal end of the
duodenum, and a similar length of longitudinal
incision is made in the distal end (Fig.18.2e).
3. The two incisions are approximated by align-
ing the end of each incision to the mid-portion
of the other incision and creating a diamondshaped anastomosis (Fig. 18.2f). Before completion of the anastomosis, a feeding tube is
passed down into the upper jejunum to eliminate distal intestinal obstruction for early
postoperative enteral feeding.
4. Duodenal web resection: For duodenal septal
stenosis, it is important to conrm the location of the membrane to the papilla of Vater,
and the web near the ampulla needs to be preserved to avoid damaging the ampulla of Vater
during excision of the web. The windsock
duodenal web may prolapse several centimeters to the distal duodenum, and a careful
search should be conducted to avoid missing
the diagnosis.
5. Large and tension-free anastomosis: The
proximal and distal duodenum should be fully
mobilized to achieve tension-free anastomosis. The length of the duodenal incision should
be large enough to reduce the risk of postoperative anastomotic stenosis and balance the
length of the incision with the degree of duodenal isolation. Diamond-shaped anastomosis
can effectively reduce anastomotic stenosis.
6. Awareness of the coassociated intestinal malformation: Duodenal atresia or stenosis is
often associated with other malformations,
including malformation, annular pancreas,
and even multiple intestinal atresia. It is mandatory to inject saline into the distal intestine
during surgery to eliminate possible
obstruction.
18.6 Technical Points andSkills
1. Distribution of cannula ports: The distance
from the operative port to the camera port was
as far as possible and ideally greater than 5 cm
to avoid the interference of robotic arm movement and even mechanical collision damage.
2. Avoid clamp damage: Because of the lack of
tactile feedback, the huge mechanical occlusal force might damage the intestine during
manipulation. Pay attention to avoid prolonged clamping and to hold the mesentery
when necessary.
3. Application of the suspension technique:
Suspending the duodenum and hepatic round
ligament through the abdominal wall is an
extremely useful technique to achieve good
exposure of the surgical eld and facilitate
intestinal incision and anastomosis due to the
small abdominal space in infants.
18.7 Postoperative Complications
1. Postoperative bleeding: Causes of bleeding
include vessel coagulation, eschar detachment, wound exudation when separating
adhesions, and plasma injury during intestinal
traction. Small amounts of bleeding can be
managed conservatively. Active bleeding and
unstable life signs indicate that surgical exploration is needed.
2. Anastomotic leakage: Poor anastomotic techniques, blood supply damage and excessive
anastomotic tension are the main causes of
anastomotic leakage. Other factors include
abdominal infection and malnutrition.
Usually, small leakages can be healed through
prolonged fasting, adequate drainage, intravenous nutritional support, and antibiotic treat-
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Q. Chen and K. Chen
ment. Massive leakage or failed conservative
treatment requires surgical intervention.
3. Anastomotic stasis: anastomotic stenosis,
severe proximal duodenal dilation, abnormal
motility, and incomplete duodenal septum
resection are the main causes of anastomotic
stasis. Conservative treatment measures such
as fasting, gastrointestinal decompression,
intravenous nutrition support and dilitation
treatment of anastomotic stenosis may be
tive bleeding and ampulla of Vater injury, and
thus signicantly reduce postoperative complications. (2) The Endowrist has 7 degrees of motion
to mimic human dexterity and can lter out the
physiological vibration of the human hands and
bear with improved control of ne movements. It
is conducive to precise separation and ne anastomosis, especially for distal collapse of the
intestine, and effectively reduces the incidence of
anastomotic complications.
effective. Reanastomosis, anastomoplasty or
tapering duodenoplasty is necessary when
conservative treatment fails.
4. Duodenal papilla injury and pancreatitis: The
ampulla of Vater is often open directly into the
medial portion of the web or open close to it.
Thus, it is mandatory to discriminate the relationship of the membrane to the papilla of
Vater before excision of the web. Pressing the
defects as well. There is no specialized equipment for children, and robotic arms are prone to
interference with each other, especially for
infants with limited abdominal space and close
distance between operating ports. For a greenhand, a lack of tactile feedback will inevitably
lead to excessive clamping force and result in
intestinal injury.
gallbladder and articially excrete bile may
help to identify the duodenal papilla. It is
rational to keep the medial portion of the
18.9 Case presentation and video
membrane intact to avoid damaging the
ampulla of Vater.
See surgery video online.
5. Missed coassociated malformations:
Congenital duodenal obstruction often accompanied by multiple atresia or stenosis in the
distal intestine. The collapsed distal intestine
References
may conceal this phenomenon. Careful exploration, catheterization and warm saline injec-
1. Kumar P, Kumar C, Pandey PR, etal. Congenital duo-
tion into the distal intestine can effectively
rule out distal segment atresia.
18.8 Comparisons with
2. Bax NM, Ure BM, et al. Laparoscopic duodeno-
3. Navarrete Arellano M, Garibay GF. Robot-assisted
Conventional Laparoscopic
Surgery
4. John JM, Anthony S. Robotic repair of congeni-
Compared with conventional laparoscopic surgery, the da Vinci robotic system has the following advantages [6]: (1) High-quality vision and
three-dimensional stereoscopic view create an
improved operative eld visibility, which may
benet a clear identication of blood vessels and
pancreatobiliary duct opening, avoid intraopera-
5. Andrea RM, Carmelle V. Romain, Fuad Alkhoury.
6. Garcia I, Armas IASD, Pimpalwar A.Current trends
However, robotic systems have intrinsic
denal obstruction in neonates: over 13 Years' experience from a single Centre. J Neonatal Surg. 2016;5:50.
duodenostomy for duodenal atresia. Surg Endosc.
2001;15:217.
laparoscopic and Thoracoscopic surgery: prospective series of 186 pediatric surgeries. Front Pediatr.
2019;7:200.
tal duodenal atresia: a case report. J Pediatr Surg.
2007;42:E31–3.
Robotic duodeno-creation duodenostomy in a pediatric patient with idiopathic duodenal stricture. J Robot
Surg 2019;13:695–8.
in pediatric robotic surgery. Isr J Med Sci. 2014;2:15.
Robotic-Assisted Ladd’s Procedure
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for Congenital Malrotation
JinfaTou andShoujiangHuang
19
19.1 Introduction
Intestinal malrotation refers to the abnormal or
incomplete rotation of the intestine with the
superior mesenteric artery as the axis during
embryonic development, which leads to variation
in the position of the intestine and incomplete
mesenteric attachment, which can cause intestinal obstruction and/or volvulus [1, 2]. The disease is mainly seen in the neonatal period, and a
few cases occur in infants or older children. In
1936, Ladd published an article on the classic
treatment of intestinal malrotation (Ladd’s operation), which laid out the foundation for the operation of intestinal malrotation [1]. In 1995, Van der
Zee etal. reported that laparoscopy was used to
successfully treat a newborn with malrotation
accompanied by volvulus for the rst time [2]. In
2005, there was the earliest report on laparoscopy
in the treatment of neonatal intestinal
malrotation.
Supplementary Information The online version contains supplementary material available at https://doi.org/
10.1007/978- 981- 19- 9693- 1_19.
The main principles of Ladd’s surgery have
not changed, including resetting and reversing
the bowel and loosening the abnormal adhesion
cord around the duodenum. Then, the duodenum and the ileocecal area are completely separated, and the mesentery is expanded. Finally,
the small intestine was placed on the right abdomen, the colon was placed on the left abdomen,
and the appendix was removed [3–12]. Whether
it is laparoscopic surgery or robotic surgery, the
principles of Ladd’s procedure are still
followed.
19.2 Indications
andContraindications
19.2.1 Indications
Intestinal malrotation was diagnosed, the condition was generally good and children with related
contraindications were excluded [3–5].
19.2.2 Contraindications
J. Tou (*) · S. Huang
Department of Neonatal Surgery, Children’s Hospital,
Zhejiang University School of Medicine, Hangzhou,
China
e-mail: toujinfa@zju.edu.cn;
huangshoujiang@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_19
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.
2. Obvious abdominal distension, intestinal
necrosis, and intestinal perforation.
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J. Tou and S. Huang
3. Very low birth weight infant, unable to tolerate pneumoperitoneum, small abdominal cavity volume, lack of robot operation space.
19.3 Preoperative Preparation
1. The patient’s general condition, abdominal
distension, bloody stools, etc., should be routinely understood before surgery, and emergency laparotomy should be performed in
cases of intestinal strangulation.
2. To perfect the preoperative examination, routine mesenteric B-ultrasound and upper gastrointestinal radiography are required to
conrm the diagnosis.
3. Routine preoperative preparation: preoperative fasting, gastrointestinal decompression,
cleaning enema, blood preparation, correction
of severe anemia, and water and electrolyte
disorders.
4. Surgical instruments: Prepare 3 sets of robotic
puncture trocars, a 3 mm auxiliary trocar,
Debakey forceps, permanent cautery hook,
3 mm laparoscopic grasping forceps, scissors, aspirator, etc.
19.4.2 Layout ofOperation Hole
1. The observation hole (No. 2 arm) is located in
the left lower abdomen at the intersection of
the transverse stripes of the abdomen and the
midline of the clavicle in patients’ BW within
3000 g. The observation hole (No. 2 arm) is
located at the umbilicus in patients’ BW more
than 3000 g.
2. The operation hole 1 (No. 1 arm) is located on
the anterior axillary line of the left upper
abdomen, 1cm below the rib;
3. Operation hole 2 (No. 3 arm) is located in the
right lower abdomen, where the transverse
stripes of the abdomen intersect with the anterior axillary line;
4. The auxiliary operation hole (assistant hole) is
located at the lower left of the midpoint of the
connection between the observation hole and
operation hole 1, as far as possible from the
operation area (Fig. 19.2).
19.4 Position andDocking
19.4.1 Surgical Position
Adopt a supine position, with head high and feet
low tilted approximately 30°, head, neck, and
trunk height 5–10cm (Fig. 19.1).
Fig. 19.1 Surgical position
FG
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131
D
Fig. 19.2 a and b: Position of Trocas (BW < 3000 g); c and d: Position of Trocas (BW ≥ 3000 g)
E
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19.5 Surgical Procedures
1. Preparation for surgery position: Adopt a
supine position, with head high and feet low
tilted approximately 30°, head, neck, and
trunk height 5–10cm.
2. The positioning layout of the operating holes.
Due to the small volume of the newborn’s
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 pneumoperitoneum was established by puncture with a
pneumoperitoneum (pressure 5–6 mmHg),
and the rst 8 mm cannula was inserted into
the main sight glass. The second 8 mm cannula is placed on the anterior axillary line of
the left upper abdomen, 1 cm below the rib, as
the main operating hole for inserting the permanent cautery hook. The third 8 mm cannula
is placed on the right lower abdomen at the
intersection of the transverse stripes of the
abdomen and the anterior axillary line, and
the operating forceps are inserted. The fourth
3 mm sleeve is placed at the bottom left of the
midpoint of the connection between the observation hole and operating hole 1, as far as
possible from the operating area, as an auxiliary operating area, used for traction exposure, suction, scissors, and needle and thread
in and out operations.
5. Routine hepatic round ligament abdominal
wall traction and suspension increase the
abdominal cavity operation space (Fig. 19.3).
6. Exploring the torsion of the superior mesenteric artery and the position of the ileocecal,
grasping forceps pull the colon upward from
the transverse colon to the ileocecal section
until the volvulus is clearly exposed. The
forceps placed in the middle of the mesentery can quickly ip and reset the intestine
counterclockwise. If it is difcult to reset,
start from the ileocecal area to the duodenum
and pull the mesentery counterclockwise to
J. Tou and S. Huang
Fig. 19.3 Suspension of the hepatic round ligament to
expose the duodenum and increase the operation space
push the bowel to reset. After reduction, the
starting part of the jejunum should be
rechecked, the ladd bands should be completely loosened close to the duodenum, the
root of the mesentery should be widened as
much as possible, and the fascia between the
duodenum and the right peritoneum should
be loosened. The duodenum and the beginning of the jejunum are straight down along
the right side of the spine. The small intestine was arranged from the right lower abdomen to the left upper abdomen, and then the
appendix was ligated and removed [3, 4, 6, 7,
13, 14].
19.6 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 the mutual interference of the mechanical arms.
2. Reposition the intestine rst during the operation to avoid incomplete or excessive reduction, and then loosen the Ladd bands.
3. The neonatal intestine tissue is fragile, so it
needs to be lifted more gently.
4. After the release is completed, the duodenal
morphology should be observed to rule out
the possibility of duodenal stenosis and other
deformities.
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19.7 Complications and
Prevention
19.7.1 Intraoperative complications
1. Paracentesis injury: In children, the abdominal space is limited. When establishing a
pneumoperitoneum or puncturing, the intraabdominal 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.
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 end-expiratory PCO2 during the operation are helpful for prevention of hypercapnia. Suspending the operation or
pneumoperitoneum can reverse dysfunction
within a short time. Once the vital signs are
unstable, robotic procedure should be transferred to an open procedure.
3. Thermal damage: Long-term electrocoagulation or electrocision may cause excessive
burns of the tissues and even delayed perforation. Therefore, the electrical separation of the
neonatal intestinal wall and cut tissues requires
a short time and high frequency.
between the duodenum, the proximal jejunum,
and the ileocecal area was expanded. Local
wounds can easily lead to adhesions, which can
cause obstruction, thereby compressing the duodenum and jejunum. It manifested as a recurrence
of biliary vomiting after patients recovered after
surgery. B-ultrasound showed no volvulus or only
a torsion of less than 180°, but abdominal X-ray
showed obvious obstruction. Once diagnosed,
surgical treatment is also needed [3, 4, 6, 7].
3. Missing distal obstruction deformity: Intestinal
malrotation is easily accompanied by the distal
duodenum or jejunum septum. Malrotation
often has a normal meconium. If there is
abnormal meconium discharge or partial
expansion of the distal intestine, the possibility
of another obstruction should be considered.
After the Ladd bands are completely released,
the shape of the duodenum needs to be
observed, and gas can be injected through the
gastric tube to assess the speed and shape of
the duodenum and jejunum [3, 4].
4. Incisional hernia: The neonatal abdominal
wall is thin; if the suture is not meticulous for
an 8-mm trocar incision, it is possible to lead
to a high-risk abdominal wall hernia.
19.8 The Dierence Between
Robotic and Traditional
Laparoscopic Procedure
The essence of robotic Ladd’s procedure is laparoscopic procedure with upgraded instruments
and equipment. The surgical principles and steps
are the same.
19.7.2 Postoperative complications
1. Recurrence of intestinal volvulus: Due to the
narrow and free root of the mesentery, if the
mesentery is not fully expanded during the
operation, volvulus or strangulation may
occur. B-ultrasound can be used for accurate
diagnosis. It usually manifests as repeated
biliary vomiting again after the operation.
Once conrmed, reoperation is needed [3, 5].
2. Intestinal adhesion obstruction: Due to the surgical release of the Ladd bands, the mesangium
19.8.1 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 limited space. At the same time,
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J. Tou and S. Huang
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.
The posterior Ladd bands on the right side of
the duodenum are deep, and traditional laparoscopic exposure is more difcult. The robot lens
is controlled by the surgeon and can cooperate
with the operating equipment, which is easier to
expose and loosen.
19.8.2 Limitations
The robotic arm occupy a certain amount of
space, and the assistant hole position selection
and operation space will be more limited than traditional laparoscopy.
The operation cost of the robot system and the
use of equipment are higher than those of traditional laparoscopes, which will increase medical
costs.
References
1. Ladd W. Surgical diseases of the alimentary tract in
infants. N Engl J Med. 1936.
2. Van Derzee DC, Bax NMA.Laparoscopic repair of
acute volvulus in a neonate with malrotation. Surgical
Endoscopy; 1995. 9:1123–4.
3. da Costa Karina M, Saxena Amulya K. Laparoscopic
Ladd procedure for malrotation in newborns and
infants. The American surgeon. 2020;87:253–8.
4. Hagendoorn J, Vieira-Travassos D, van der Zee
D. Laparoscopic treatment of intestinal malrotation
in neonates and infants: retrospective study. Surg
Endosc. 2011;25:217–20.
5. Aurélien S, Igor D, Jérome D, et al. Outcomes
of laparoscopic and open surgical treatment of
intestinal malrotation in children. J Pediatr Surg.
2020;55:2777–82.
6. Svetanoff WJ, Sobrino JA, Sujka JA, St Peter SD,
Fraser JD.Laparoscopic Ladd pocedure for the management of malrotation and volvulus. J Laparoendosc
Adv Surg Tech A. 2020;30:210–5.
7. Ooms N, Matthyssens LE, Draaisma JM, de Blaauw
I, Wijnen MH.Laparoscopic Treatment of Intestinal
Malrotation in Children. Eur J Pediatr Surg.
2016;26:376–81.
8. Isani MA, Schlieve C, Jackson J, et al. Is less
more? Laparoscopic versus open Ladd’s procedure in children with malrotation. J Surg Res.
2018,229:351–6.
9. Ferrero L, Ahmed YB, Philippe P, et al. Intestinal malrotation and volvulus in neonates: laparoscopy versus
open laparotomy. J Laparoendosc Adv Surg Tech A.
2017,27:318–21.
10. Catania VD, Lauriti G, Pierro A, et al. Open versus
laparoscopic approach for intestinal malrotation in
infants and children: a systematic review and metaanalysis. Pediatr Surg Int. 2016,32:1157–64.
11. Zhang Z, Chen Y, Yan J. Laparoscopic versus
open Ladd’s procedure for intestinal malrotation
in infants and children: a systematic review and
Meta-analysis. J Laparoendosc Adv Surg Tech A.
2022,32:204–12.
12. Xie W, Li Z, Wang Q, et al. Laparoscopic vs open
Ladd’s procedure for malrotation in neonates and
infants: a propensity score matching analysis. BMC
Surg. 2022;22:25.
13. Svetanoff WJ, Srivatsa S, Diefenbach K, et al.
Diagnosis and management of intestinal rotational
abnormalities with or without volvulus in the pediatric
population. Semin Pediatr Surg. 2022,31:151141.
14. Ooms N, Matthyssens LE, Draaisma JM, et al.
Laparoscopic treatment of intestinal malrotation in
children. Eur J Pediatr Surg. 2016,26:376–81.
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