Fig. 15.1
Transverse incision in the bulbus duodeni
Fig. 15.2
First suture through the distal duodenum
Fig. 15.3
Approximation of first suture from midway bulbus to superior edge of distal duodenum
Fig. 15.4
Completion of anastomosis
15.6 Postoperative Care
The patients are kept nil per mouth for 24 h, after which feeding is started with 8×10 ml, irrespective of any gastric retention. Feeding is extended according to age and weight over the following days. Retentions up to 30 cc are accepted and given back. It is better not to measure retentions, but observe the child clinically and adjust feeding regimen accordingly.
Feeding and admission times are usually more dependent on concomitant anomalies like cardiac abnormalities or Down syndrome.
15.7 Personal Experience
We described the first case of laparoscopic repair of duodenal atresia in 2001 [4]. In a first series from 2000 to 2005, 22 children were operated laparoscopically. In four cases the procedure was converted. In five patients there was leakage of the anastomosis. This was reason to stop the laparoscopic approach at that moment until the procedure was adjusted sufficiently to ban out any more leakage.
With increasing experience and changing to a running suture that secured the anastomosis, we picked up the procedure again. From 2008 to March 2015, another 22 children were operated laparoscopically without any more complications. All procedures could be completed laparoscopically [3].
15.8 Discussion
Repair of duodenal atresia is one of the most complex minimal invasive procedures. This is mainly because of the limited space available. In thoracoscopic repair of esophageal atresia, the rigid thoracic cage secures some space. In the abdomen with low pressures of 5–8 mmHg, the overlying liver and moving intestines, next to gas leakage along the trocars, leaves a limited space for moving around. Often an extra trocar is placed in the epigastrium to lift up the liver to give additional exposure. Also the liberal use of stay sutures gives more stability to the operating field. It helps if the assistant that holds the camera pulls on the umbilical trocar to give additional space. The major step forward in determining success was the use of running sutures that give an even tension along the whole anastomosis. Since adjusting this technique, we have seen no more incidents of leakage.
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