**4.3 Operative techniques**

### *4.3.1 Laparoscopic Membranectomy and Heineke-Mikulicz Duodenoplasty*

The patient is placed in the reverse trendelenburg position at the lower edge of the operating table to provide convenient access to the operating field for the surgeon (**Figure 4**). Veress needle access is performed and three laparoscopic ports are installed: (1) optical port in the left iliac region, (2) manipulation port in the left upper quadrant, (3) manipulation port in the right iliac region. The optical port is placed lower to allow for better visualization of the duodenal malformation (**Figure 5**). This port placement allows enough working space to perform duodenal anastomosis.

Low-pressure pneumoperitoneum with CO2 is used: pressure of 8 mmHg and flow of 2 L/min. The first step is a transabdominal suture around the round ligament of the liver to fixate the liver to the abdominal wall. This maneuver improves visualization of the duodenum, especially its distal part. The hepatic flexure of the colon is mobilized using blunt or sharp dissection of its ligaments. A "no-touch" technique is preferred, capturing the surrounding tissues without crushing the intestinal walls with a clamp. Mobilization should be carried out widely enough to separate the transverse colon from the duodenum and allow for sufficient access to the duodenum. Importantly, as the duodenum bends around the pancreas it can be located either anteriorly or posteriorly, depending on the patient's unique anatomy. If the bulb of the duodenum is significantly stretched, a transparietal traction suture can be placed on the anterior

**Figure 4.** *Positioning of the patient for a laparoscopic reconstruction of duodenal atresia.*

### **Figure 5.** *Placement of the laparoscopic ports.*

### **Figure 6.**

*Operative field with the optical port (1), trocars for manipulative instruments (2), traction suture over the round ligament of the liver (3), and traction suture on the proximal part of the duodenum (4).*

wall of the bulb and brought out through the skin, allowing for mobilization of the distal portion of the duodenum (**Figure 6**). Lysis of adhesions can be performed with blunt dissection.

The location of the obstruction must be precisely defined. The obstruction can result from an annular pancreas, duodenal stenosis, or true duodenal atresia. At the time of mobilization of the distal portion of the duodenum, the gastrointestinal tract can be assessed for malrotation [68]. After that, the proximal and distal parts of the duodenum are identified and mobilized (**Figure 7**). Further steps depend on the type of duodenal anomaly.

The findings determining the type of reconstruction are (a) membranous, type I, or (b) other forms of obstruction with separation of the muscle membranes of disconnected segments, including duodenal atresia with (type II) or without (type III)

**Figure 7.** *Duodenal atresia type 1.*

**Figure 8.** *Longitudinal duodenotomy over the site of obstruction.*

a fibrous cord and an annular pancreas. Membranous forms of duodenal obstruction are repaired using a longitudinal duodenotomy over the site of obstruction with incision of the proximal and distal portions of the duodenum (**Figures 8** and **9**). Then, the membrane is captured with a delicate atraumatic clamp and excised circularly with coagulation micro-scissors (**Figures 10** and **11**). Particular care is necessary for dissecting the duodenum at the ampulla of Vater [69]. The final step of the operation is transverse suturing of the duodenal lumen with interrupted absorbable sutures (**Figures 12** and **13**).

*Duodenum after its excision. 1 - proximal part, 2 – Distal part, 3 – Duodenal membrane.*

**Figure 10.** *Laparoscopic excision of the duodenal web.*
