1. Laparoscopic Management of Small Intestinal Atresia George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, MO

2. Duodenal Atresia/Stenosis Most common site neonatal intestinal obstruction Associated with Trisomy 21 and annular pancreas Error in re-cannalization 50% will have another organ system anomaly

3. Duodenal Atresia/Stenosis Type 1 – 92%  intact mesentery; web b/w 2 segments  obstruction usually near ampulla

4. Duodenal Atresia/Stenosis  Diamond-shaped duodenoduodenostomy is the preferred technique

5. Laparoscopic Approach Baby supine, foot of bed Suture around falciform Liver retraction Umbilical port – telescope/camera Working ports right side of abdomen

6. Laparoscopic Approach Use regular cautery with fine tip needle

7. Laparoscopic Approach U-clips (Medtronic) used for anastomosis

8. Laparoscopic Approach

9. Laparoscopic Duodenoduodenostomy

10. Concurrent Series 2003 - 2006 Retrospective study 28 babies – 14 open, 14 laparoscopic Open: 11 atresia, 3 stenoses Laparoscopic:12 atresia, 2 stenoses No difference in age, weight, chromosomal anomalies, incidence of heart disease b/w 2 groups AAP, 2007

11. Concurrent Series 2003 - 2006 AAP, 2007 Open (14) Laparoscopic (14) P Value Op Time (min)961160.09 Anastomotic Leaks001.00 Initial Feed (days)11.35.90.002* Full Feed (days)16.910.20.008* Postoperative hospitalization (days) 20.113.00.008*

12. Conclusions Laparoscopic approach for duodenal atresia is safe and efficacious Patients undergoing the laparoscopic approach had more rapid advancement of feedings and shorter hospitalization Use of the U-clips allows for a faster operation if an interrupted suture technique is preferred

13. Jejunoileal Atresia Due to late intrauterine mesenteric vascular accidents More common than duodenal atresia (1/1000 live births) Uncommon to have other anomalies

14. Jejunoileal Atresia Diagnosis usually evident More distal the obstruction, more distended loops of bowel Contrast enema usually helpful

15. Minimally Invasive Management Umbilical incision Extend if necessary Exteriorize bowel

16. Minimally Invasive Management Extracorporeal anastomosis RLQ or RUQ incision, if necessary

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