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126
M. McHoney
19.3 Positioning, Port Siting,
Ergonomic Considerations
and
The infant (with nasogastric tube in situ) is placed in the
supine position at the foot of the operating table (Fig. 19.1a)
or across the table for good ergonomics. Usually, no other
specific positioning is required. Occasionally, the pylorus is
tucked under the liver, and a small amount of head up-tilt
will encourage the rest of the intestines to fall away from the
operative field, facilitating access to the pylorus.
A 5-mm supraumbilical incision is made through layers
into the abdominal cavity. A 5-mm primary port is inserted
a
and secured (Fig. 19.1b, c). (The supraumbilical incision is
preferable to the infraumbilical one, as it may be extended to
convert to an open supraumbilical approach if necessary.)
Pneumoperitoneum is established to 6 mmHg pressure,
which may be increased to 10 mmHg if required and tolerated. The initial flow rate is set between 0.5 and 1 L/min.
Two other working instruments are placed in the right and
left sides of the upper abdomen. It is worth noting that the
best ergonomics are achieved with the surgeon’s left-handed
instrument (grasper) placed laterally in line with the duodenum, whereas the surgeon’s right-handed instrument is best
placed medially almost vertically over the pylorus (Fig. 19.2).
b
Fig. 19.1 Patient position (a) and ports (b). Patient positioning at the end of bed and the positioning of instruments. The screen is placed above
the patient for good visualisation
19 Pyloric Stenosis
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19.4 Relevant Anatomy
127
Fig. 19.2 Anatomy of the pyloric tumour. The falciform ligament is
seen in the left-hand side running towards the liver, beneath which lies
the pylorus. The prepyloric vein of Mayo may be identified. The intended
incision is sited on a relatively avascular line along the pylorus
128
19.5 Surgical Technique
Two additional working instruments are passed directly into
the abdomen (without ports) via stab incisions using a #11
blade and operation procedes as in the following figures
(Fig. 19.3, 19.4, 19.5, 19.6, 19.7, 19.8, and 19.9).
M. McHoney
Fig. 19.3 Stab incision for first grasper. The first incision is used to
place a grasper is in the patient’s right upper quadrant (to enter below
the liver edge) so that the duodenum can be grasped easily and
stabilised
Fig. 19.4 Grasper inserted in the right upper quadrant. The grasper is
inserted directly through the abdominal wall, below the liver, and
extending below the falciform ligament to the pylorus
Fig. 19.5 Position of the pyloromyotomy blade. The second instrument (initially, the pyloromyotomy blade) is placed in the epigastrium
below the liver and almost vertically over the pylorus. Initially, this is a
blade for incising the pylorus and later a spreader to open the pylorus
Fig. 19.6 Extent of hypertrophied pyloric muscle. The image shows
the extent of pyloric muscle thickening by palpation between instruments. A relatively avascular plane may be seen in the middle of the
pylorus
19 Pyloric Stenosis
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129
a
Fig. 19.7 Incision on the pylorus. The duodenum is grasped with the
grasper to stabilise the pylorus. (a) The incision in the pylorus is initially
made in the middle of the pylorus (thickest area of hypertrophy and
b
least likely to perforate) and is extended superficially along the length
of the pyloric thickening. (b) A gentle twist of the blade helps indicate
a sufficient incision into which the spreader can be inserted
Fig. 19.8 Spreading of the pyloric muscle. A spreader introduced via
the right-handed working incision into the middle of the tumour, with
careful but sustained spread, is used to deepen and spread the
myotomy
Minor oozing is common and not a problem. It is not
mandatory to check for leaks if the mucosa has been visualised clearly, with no obvious leaks. If desired, 20–40 mL of
air may be injected via the nasogastric tube to distend the
stomach. This air then is coaxed into the pylorus with pressure from the instruments, and any leak should be obvious.
Leaks may be repaired primarily (via an open or laparoscopic approach, depending on operator’s preference or
experience), with or without an omental patch. The wounds
Fig. 19.9 Completing the myotomy. The myotomy is completed by
spreading along the length of the pylorus with pouting of the gastric
mucosa throughout the length of the incision. Any obvious leaks of air or
bile should by looked for at this point. Adequacy may be checked by
grasping the sides of the tumour and ensuring independent movement
are closed with absorbable sutures to the muscle and a subcuticular skin stitch or skin glue. The wound used for the
working instruments should be closed before desufflation of
the abdomen to help prevent omentum prolapse during closure. The nasogastric tube may be removed at the end of the
operation. Feeds may be started and graduated according to
local policy. We feed patients after 4–6 h and graduate to full
feedings in three or four increments. Infants may be discharged when on full feedings.
130
M. McHoney
19.6 Alternatives
• Although a supraumbilical approach is described and
preferable, an infraumbilical cut-down may be used.
• A bowel-holding (Johan) forceps may be used in place of
the pyloric spreader.
• If no suitable 3- (or 5-) mm blade is available, a 3-mm
hook diathermy may be used to perform the initial myot-
omy. However, in the author’s opinion, this requires some-
what more experience and is less controlled than the blade.
19.7 Highlights and Pitfalls
• Place the left-handed instruments laterally (to avoid the
falciform ligament) but the right-handed instrument
medially (almost vertically over the pylorus). Placing the
right- hand instrument too laterally makes performance
of the myotomy very unergomonic and may cause
difficulty.
• It is safest to begin the myotomy with the blade in the
middle of the tumour (where it is thickest); this helps
avoid perforation. The myotomy incision may be deeper
in the middle but more superficial in the lateral ends of the
tumour.
• Initial firm and sustained spread in the middle of the pylorus can complete the myotomy in one swift movement
with ease and efficacy.
• Omental prolapse through the accessory site may be minimised by closing these wounds under laparoscopic
vision with the abdomen still inflated. This keeps the
abdominal wall away from the roaming omentum until
securely closed.
• The cosmetic outcome is excellent (Fig. 19.10).
Fig. 19.10 Cosmetic outcome. The cosmetic outcome is excellent,
with imperceptible scars. This image shows the cosmetic appearance 3
years after laparoscopic pyloromyotomy in one patient
19 Pyloric Stenosis
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131
References
1. Hall NJ, Pacilli M, Eaton S, Reblock K, Gaines BA, Pastor A, et al.
Recovery after open versus laparoscopic pyloromyotomy for pyloric
stenosis: a double-blind multicentre randomised controlled trial.
Lancet. 2009;373:390–8.
2. Sola JE, Neville HL. Laparoscopic vs open pyloromyotomy: a systematic review and meta-analysis. J
3. Carrington EV, Hall NJ, Pacilli M, Drake DP, Curry JI, Kiely EM,
al. Cost effectiveness of laparoscopic versus open pyloromyot-
et
omy. J
Surg Res. 2012;178:315–20.
Pediatr Surg. 2009;44:1631–7.
Duodenal Atresia Repair
Aimee Gibson and Nada Sudhakaran
Abstract
Laparoscopic duodenal atresia repair (duodenoduodenostomy) was initially described at the
beginning of the twenty-first century; some centres abandoned the laparoscopic approach
due to high anastomotic leak rates [1]. One particular centre [1] reported an anastomotic
leak rate of just under 30
some time. After modifying their technique from interrupted to continuous suturing, they
revisited the procedure in a new cohort of patients and, with this, had no complications. As
a result, they have been performing and teaching the procedure ever since. Others have also
reported similar results [1]. They have themselves suggested that laparoscopic duodenoduodenostomy should be restricted to paediatric centres with extensive laparoscopic
experience.
%, in their initial early series before abandoning the procedure for
20
Keywords
Laparoscopic duodenal atresia repair • Duodenoduodenostomy
20.1 General Information
Laparoscopic duodenal atresia repair (duodenoduodenostomy) was initially described at the beginning of the
twenty- first century; some centres abandoned the laparoscopic approach due to high anastomotic leak rates [1]. One
particular centre [1] reported an anastomotic leak rate of
just under 30
ing the procedure for some time. After modifying their
technique from interrupted to continuous suturing, they
A. Gibson • N. Sudhakaran, MD (*)
Paediatric Surgery, Gold Coast University Hospital,
Queensland, Australia
%, in their initial early series before abandon-
revisited the procedure in a new cohort of patients and, with
this, had no complications. As a result, they have been performing and teaching the procedure ever since. Others have
also reported similar results [
gested that laparoscopic duodenoduodenostomy should be
restricted to paediatric centres with extensive laparoscopic
experience.
Advantages of the laparoscopic approach include faster
recovery and earlier resumption of oral feeding, leading ultimately to earlier discharge.
1]. They have themselves sug-
© Springer-Verlag Berlin Heidelberg 2017
M. McHoney et al. (eds.), Color Atlas of Pediatric Anatomy, Laparoscopy, and Thoracoscopy,
DOI 10.1007/978-3-662-53085-6_20
133
134
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A. Gibson and N. Sudhakaran
20.2 Relevant Anatomy
There are three categorised types of duodenal atresia. Type 1
involves either a diaphragm or web that includes submucosa
and mucosa. Type 1a is termed the “windsock” deformity,
where the diaphragm has ballooned distally. 1b involves a
membrane without ballooning, whereas 1c involves a web
between the duodenal segments. Type 2 atresias have a
dilated proximal segment, with collapsed distal segment
connected by a fibrous cord. Type 3 atresias have no connection between proximal and distal segments. Most atresias
occur at the level of D2 (Fig. 20.1).
More than 50 % of duodenal atresias are associated with
other congenital anomalies, and approximately 30 % are
associated with trisomy 21. Other associations include cardiac anomalies and other gastrointestinal abnormalities, the
most important of which to recognise is malrotation.
Diagnosis may be made antenatally, with findings of a
double bubble sign. Most were detected within the seventh
and eighth months of pregnancy.
Although the duodenum has numerous close anatomical
relations, those most important in laparoscopic duodenoduodenostomy include:
1. The falciform ligament: containing the left umbilical
vein, it should not be transected but carefully secured
superiorly to retract the liver.
2. The right lobe of the liver: in infants, the liver is quite
large with respect to the abdominal cavity size and hangs
over the duodenum.
3. The transverse colon: also overlying the duodenum, it
must be gently peeled away from the duodenum to get
exposure.
4. The pancreas: locating the pancreas helps identify the
proximal and distal parts of the duodenum in duodenal
atresia as it generally separates the two. In some cases, an
annular pancreas may be identified
20.3 Working Instruments
• 3 mm hasson port
• Either 30° or 0° laparoscope
• 3 mm needle holders
• 3 mm scissors
3 mm suture cutting scissors
•
• 3 mm Maryland forceps
• 2 × 3 mm soft bowel grasping forceps
• 3 mm monopolar hook
• 3 mm Reddick Olsen grasper
• 3 mm bipolar scissors/grasper (optional)
II III
20 Duodenal Atresia Repair
Ia Ib
135
Ic
Fig. 20.1 There are three categorised types of duodenal atresia. Type
1 involves either a diaphragm or web that includes submucosa and
mucosa. Type 1a is termed the ‘windsock’ deformity, where the diaphragm has ballooned distally. Type 1b involves a membrane without
ballooning, whereas type 1c involves a web between the duodenal seg-
ments. Type 2 atresias have a dilated proximal segment, with collapsed
distal segment connected by a fibrous cord. Type 3 atresias have no
connection between proximal and distal segments. Most atresias occur
at the level of D2
136
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20.4 Positioning, Port Siting,
Ergonomic Considerations
and
The baby is positioned supine with the legs as close to the
lower end of the operating table as possible. A 3 mm hasson
port is placed at the umbilical fold and two stab incisions are
placed at the level of the umbilicus on either flanks (Fig. 20.2).
The portless approach is used to introduce the suture with its
needle into the abdominal cavity.
A. Gibson and N. Sudhakaran
Fig. 20.2 A 3-mm hasson port is placed at the umbilical fold and two
stab incisions are placed at the level of the umbilicus on either flanks
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