Malrotation Infant

This video represents a laparoscopic lad's procedure for malrotation in an infant who presented with repetitive bilious vomiting. An upper sheet GI showed a redundant duodenum which did not cross the midline. The room set up as it shows. The surgeon is at the end of the table with the baby brought down to the foot of the table in order to allow the surgeon to be in line with the foregu. Trochar placement is as seen. A 4 or 5 millimeter port is placed in the umbilicus, and right and left hand operating ports are placed either side of the umbilicus. In a small infant, the right hand port is placed above the umbilicus so that the right hand does not conflict with the scope. The initial dissection takes place under the liver. A very dilated proximal duodenum can be seen. Adhesions and omentum were taken down off of this using the 3 millimeter sealer. You can see that the 3 millimeter sealer can be used to safely grasp the bow and act as a forceps. Which is atraumatic to the bowel. The duodenum is followed distally, taking down all attachments. To fully mobilize it. The first portion of the duodenum is extremely dilated. In the left hand, there is a 3 millimeter bowel grasper, which is also atraumatic. The multiple dense adhesions to the proximal duodenum, and it can be seen to be quite torturous. These can be safely taken down using the sealer, dissecting them off the bow, and then sealing and gently tearing them off the surface of the duodenum. Because of the minimal energy spread of the sealer, it is very safe to dissect in this fashion. You also see that the bow can be grasped immediately after the sealer is activated without any evidence of any heat injury to the bow. You find this much more useful than using a hook, which had significant energy spread and also could not be used to grasp the bell. You can see that there are many dense adhesions around the dude. But the dissection is continued in a proximal to distal fashion, exposing now the second portion of the duodenum. Continued upward pressure is placed on the freed portion of the duodenum, exposing other adhesions. Trying to completely free up the torturous. To demon. Pas minimal bleeding using this technique and no injury to the bowel. Now see the cut a lobe of the liver. As we continue to free up the redeemer. As is common in these cases, the duodenum. Goes towards the retroperitum, and this is the most difficult part to mobilize. You can see the transverse colon attachments up to the 2 and 3 portion of the duodenum. These adhesions Some of which are consistent with loud bands can be extremely thick and dense and difficult to take down. But again, by dissecting them off. Of the duodenum using the. Section and grasping properties of the sealer, this can be done atraumatically. Because of the posterior attachments, it was felt at this point that complete mobilization of the transverse. And proximal or ascending colon is necessary. Here you can see some stretched lateral wall attachments. Between the cecum And the retroperitoneum. These are extremely flimsy and are easily taken down using the ceiling. By doing this, we will get exposure to the. Complete aspect of the duodenum, which is quite torturous. With these lads' bands mobilized. The colon easily flips over. Into the. That's portion of the abdomen. Where you can see some of the lads bands crossing it. Over portions of the. Uh, Ilium. Also causing a partial obstruction. Again, the minimal energy spread from the sealer allows this device to be used in close proximity to the small bowel without any risk of injury to it. Now see the last of the lad's bands as it traverses across the duodenum which was causing the proximal obstruction. There we can see the de demon doubling back on itself. These last Attachments allow us to mobilize the colon completely into the left. Portion of the abdomen and now the kinking retroperineal attachment of the duodenum can be mobilized. And taken. You're now able to see the. Posterior aspect of the duodenum and completely mobilize it. This will allow us to run the bow. And completely de-rotate the bowel. To eliminate the risk of loulus in the future. Again, these last posterior attachments could neither be Reached until the lad's bands had been completely divided. Now we're able to grasp the Frieda Dudenum. And pull it down to ensure that we are able to straighten the duodenum as you see here. Now the duodenum is completely freed, and you can see the area where it was transitioned in the proximal portion was extremely dilated. The bow is now run from proximal to distal to completely de-rotate the bow. And this again can be done safely with the sealer asking, acting as a. A traumatic bowel grasper. The jaws are not quite as large as the 3 millimeter valve grasper, but they work quite effectively. We use it during this portion of the procedure because often other bands are. Encountered, and this allows us to immediately seal them and divide them. The bowers run all the way until the. Terminal ileum and cecum are. Reached. Here you can see the valve almost completely derotated. The enlarged lymph nodes in the mesentery and the chyous appearance within the bowel show the evidence of chronic mild obstruction. Finally, the terminal ileum and the cecum are reached. And at this point, We mobilize. The mesentery of the appendix so that it can be removed. At this point of the operation, all of the colon is on the left and the small bowel is on the right. And we've completed the lab's procedure. With the appendiceal mesentery taken down with the sealing, the appendix can either be taken intracorporeally or in a small infant, with a small appendix can be brought out through the right through know of the trochar site. And then amputated exporially as seen here.