Double bubble sign demonstrated on plain radiograph. From Kuenzler K, Rothenberg S. Duodenal Atresia. In: Mattei P. Fundamentals of Pediatric Surgery. Springer, New York 2011 . Reprinted with permission.
In cases of duodenal stenosis or unclear plain radiologic findings, an upper gastrointestinal contrast study can be performed.
Given the disease process’ association with congenital anomalies, it is important to obtain other imaging studies for evaluation. An echocardiogram should be performed in order to rule out any cardiac anomalies. It is also recommended to obtain chest X-rays to rule out vertebral anomalies. Ultrasonography assesses for abnormalities in the renal system .
Indications for surgery include a working diagnosis of an obstructive process as evidenced by imaging studies. If there is suspicion of an intestinal malrotation, the operation should be expedited to prevent ongoing bowel ischemia from volvulus.
This procedure needs to be performed in an operating theater capable of performing laparoscopic/minimally invasive procedures. The anesthesiologist must be familiar with neonates and manipulating an orogastric tube during the anesthesia. In case of a windsock deformity (Type I), advancing an orogastric tube facilitates localization of the web in the duodenum by the surgeon. A simple web can be operated by a longitudinal antimesenteric incision and excision of the membrane.
To access the duodenum, the liver is retracted upwards; this is key to exposure. Also, gastric decompression is important in order to reduce the size of the dilated stomach and aid in visualization of the operative field. The right colon may also need to be mobilized in order to gain access to the duodenum.
The patient is placed in a frog-leg position on the operating table. General anesthesia is induced and a bladder catheter is placed. An orogastric or nasogastric tube is usually placed pre-operatively. The patient should be secured to the table, as the table is often shifted into a reverse Trendelenburg position. The scrub nurse is positioned to the patient’s right side, and the camera holder is positioned to the left. The surgeon stands at the end of the table, at the feet of the patient  (Fig. 25.2). Laparoscopic monitors are placed at the head of the bed.
Positioning of the patient. From Zee D, Klaas, MA. Laparoscopic Treatment of Duodenal and Jejunal Atresia and Stenosis. In: Klaas MA et al. Endoscopic Surgery in Infants and Children. Springer, Berlin/Heidelberg 2008 . Reprinted with permission.
Two to three 3-mm trocars are needed for the working instruments and a 5-mm trocar is used for the laparoscope to be placed via the umbilicus. Some surgeons prefer the portless technique and advance working instruments through stab incisions. A 5-mm scope with a length of 24 cm is ideal. Angled lenses are preferred, and often a 30-degree scope is employed. A liver retractor should also be available if the liver obstructs the view and needs to be lifted. Alternatively, a transcutaneous suspension U-stitch around the falciform ligament can be placed. 5–0 absorbable braided sutures are used for the bowel anastomosis, and the stitching is performed intra-corporeally.
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Three to four trocars are needed in total. An intra- or infra-umbilical incision is made and entry into the abdomen is gained through an open technique. CO2 pressure is set to 8 mmHg at an initial flow of 1 L/min for the neonate . Trocars number two and three are placed on either side of the umbilicus. The liver is retracted upwards with an instrument through an additional subxiphoid stab incision or trocar. This can be done in a variety of methods including the use of a liver retractor, an Allis grasper, or a suture underneath the falciform ligament, as described above (Fig. 25.3). The proximal, dilated duodenum is usually easily visualized at this point. Distally, the atretic segment of duodenum is found and bluntly mobilized. Transcutaneous holding sutures help to expose and hold the proximal segment. After appropriate mobilization has been performed, the proximal dilated segment is opened in a transverse fashion using a pair of scissors or the hook cautery. The small distal segment is opened longitudinally in identical length. An anastomosis is performed using either interrupted or continuous sutures with a 5–0 absorbable suture in a diamond shape configuration (Fig. 25.4).
Port placement. From Zee D, Klaas, MA. Laparoscopic Treatment of Duodenal and Jejunal Atresia and Stenosis. In: Klaas MA et al. Endoscopic Surgery in Infants and Children. Springer, Berlin/Heidelberg 2008. Reprinted with permission.
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