*4.3.2 Laparoscopic Kimura anastomosis*

In patients with duodenal atresia type II and type III, a diamond-shaped Kimura anastomosis is performed (**Figure 14**). The technique of laparoscopic diamondshaped anastomosis does not differ from the open procedure (**Figure 15**) [39, 70]. A transverse duodenotomy of the dilated proximal part of the duodenum and a longitudinal incision of the distal collapsed segment are performed using a needle or hookshaped electrode (**Figures 16** and **17**). A transparietal traction suture is placed on the proximal portion of the duodenum, which is brought to the anterior abdominal wall to allow for fixation of the bowel to allow for duodenal anastomosis creation.

**Figure 11.** *Lumen of the duodenum after resection of the duodenal web.*

#### **Figure 12.**

*Suturing of the longitudinal duodenotomy in a transverse fashion.*

The technique of laparoscopic Kimura anastomosis involves placement of separate sutures (PDSII 6/0), on the posterior (**Figure 18**) and then the anterior wall of the duodenal junction (**Figure 19**). To achieve the diamond shape, the first suture is placed between the right point of the transverse duodenotomy and the middle of the right part of the longitudinal duodenotomy. Subsequent stitches are placed bilaterally to the right and left of this initial suture so that the final stitches of the posterior wall of the anastomosis are placed between the right and left ends of the transverse

**Figure 13.** *Duodenal anastomosis after resection of the duodenal web.*

**Figure 14.** *Duodenum type 3. 1 – Proximal segment, 2 – Distal segment, 3 – Head of the pancreas.*

incision and the middle of the longitudinal incision on both sides. Thus, the lower triangle of the future diamond-shaped anastomosis is formed. The anterior wall of the anastomosis is created in a similar way, connecting initially the central points of the incisions, and then the peripheral ones. The result of these complicated actions on small objects in a limited field for manipulation is a wide duodenoduodenal anastomosis. Van der Zee D. places the second suture between the left corner of the

**Figure 15.** *A diamond-shaped anastomosis [37].*

**Figure 16.** *Excision of the proximal segment of the duodenum.*

transverse duodenotomy and the middle of the left edge of the longitudinal duodenotomy (outside-in, inside-out). After tying this stitch, the needle is placed inside the intestinal lumen and a continuous suture is placed on the posterior wall from inside

**Figure 17.** *Excision of the distal segment of the duodenum.*

**Figure 18.**

*Duodenal anastomosis described by Kimura K. et al. [33]. Creation of the posterior wall of the anastomosis.*

the lumen. The posterior wall of the anastomosis can be easily visualized for a future continuous suture by applying traction to the left stitch.

At the right end of the suture line on the posterior wall, the needle is brought out and tied with the short end of the first suture. The same thread can be used to

**Figure 19.** *Duodenal anastomosis described by Kimura K. et al. [33]. View at the end of the procedure.*

perform a continuous suture on the anterior wall of the anastomosis. In cases of an annular pancreas, the anastomosis is created in the form of a "bridge" over the area of ectopic glandular tissue-duodenal "bypass" (**Figures 20** and **21**). It is important to make sure that this is exactly the horizontal part of the duodenum, not the loop of the jejunum because this can lead to the creation of a blind loop. At the end of the operation, no feeding tube is passed through the area of the anastomosis as there is no need to inspect for other membranes or obstruction sites, given that these are extremely rare (less than 1%) [71]. The anesthesiologist performs the white test (injection of a fat emulsion solution for parenteral nutrition into a pre-installed gastric tube). This maneuver confirms there is no anastomotic leak or intestinal obstruction in the distal part of the small bowel.
