NEC small bowel stricture

This video shows a stapled resection and anastomosis in a preterm infant. A 28-week premature infant who weighed 900 g was born with a tracheoesophageal fistula. The patient underwent successful ligation and gastrostomy tube but developed necrotizing enterocolitis 3 weeks later. It was treated medically, but the child developed a stricture which was shown on upper GI at 8 weeks of age. This was the room set up for the laparoscopic resection. The baby is at the end of the table, and the surgeon is at its feet. Three ports were used a 4 millimeter, 30 degree scope and 23 millimeter ports, with the right-handed port later being changed to a 5 for the 5 millimeter stapler. Upon entering the abdomen, the ileocecal valve was found, and then the bowel was run proximally towards what was assumed to be a mid ileal stricture. While doing this, a Meckel's diverticulum was discovered. The 3 millimeter sealer was used to free up the mesentery going to the meals for later resection. The bowel was then run more approximately until the area of the stricture was identified. This was approximately mid ileum. At this point, the bowel became extremely adherent and difficult to move, and upon further manipulation, it appeared that a loop of bowel was densely adherent to the capsule of the spleen. This appeared to be the point of obstruction. Using the 3 millimeter sealer, the bowel was gently dissected off the spleen, preserving the splenic capsule with no bleeding. Gradually the bowel was freed up enough so that the area of the obstruction could be identified. Here you see the last remnants of the attachment to the spleen. During this mobilization. A small enterotomy was made, which was later used to show the exact site of the obstruction. With the valve safely mobilized off of the spleen and the splenic capsule remaining intact. Adequate mobilization of the bowel was obtained do the resection. Here you see the enterotomy and the forceps being passed into the bowel showing complete obstruction of the bowel at this point. The decision was made at this point to perform an intracorporeal resection and anastomosis. The mesentery of the affected bowel was sealed using the 3 millimeter sealer. And with the mesenteric defect in place, the 5 millimeter stapler was introduced through the right hand port. And used to resect the bow. The stapler lays down 2 millimeter staples, 4 rows of which are then divided between two rows equally. Here you see the divided bowel with no intraluminal contaminants entering the peritoneal cavity. The mesentery of the affected bowel was then sealed and stripped off the affected piece of bowel. This was quite effective and it was not necessary to introduce scissors to divide the mesentery. Once the mobilization was clearly past the area of the stricture, another application of the 5 millimeter stapler was used. To make the distal resection. The resected specimen was then placed up in the right upper quadrant for later use. A 3-0rolene stitch was then passed through the anterior abdominal wall and then passed through the two ends of the bowel to set up a side to side anastomosis. This technique provides excellent exposure and acts as an excellent retractor to align the two pieces of bow. On the proximal end of the anastomosis, a 30 vicro was used intracorporeally to align the bowel in this area. With this done, a 3 millimeter hook cautery was used to make enterotomies in both the proximal and distal segments for entrance of the 5 millimeter stapler to perform the side to side anastomosis. Each of the otomies was widened slightly with a 3 millimeter barrel. The stapler was then again reintroduced through the right-hand trocar. And Each arm was introduced into the. Two sides of the bow With this done, an excellent alignment was obtained, and a side to side anastomosis was performed. Here you see the residual enterotomy and looking in the wide anastomosis. The leftover enterotomy was closed with a running 30 viral suture. And this was done quite easily. The 30 prolene state suture was left in place until this closure was complete. The running suture was tied. To the residual 30 viral stay suture which had been placed to align the proximal ends of the valve. Here you can see the Completed suture line just prior to. Ting. The knot at the end of the suture. Because of the very small intraabdominal space, only a limited portion of the trochar can be inserted into the abdominal cavity. It is also possible to use stab wound incisions if the surgeon desires. With the anastomosis completed, attention was then turned back to the Meckel's diverticulum. 3 millimeter bow clamp was used to compress the base of the metals to. Make sure that all gastric mucosa would be resected and this was normal mucosa. A single application in the 5 millimeter stapler easily resected the mechel stump. This was then removed through the 5 millimeter trocar site, and here you see the Meckels. Outside of the abdomen. The thumb of a 7 glove was then inserted through the 5 millimeter trocar. And the resected specimen was placed in the Manufactured specimen bag, which was then brought out through the 5 millimeter port side. Here you see the specimen coming out. The entire operation took 75 minutes, and the child tolerated the procedure extremely well. Here you can see the specimen, which is approximately 3.5 centimeters in length. You used to see the baby immediately postoperatively. Uh, and here is the child one month after the reception. The baby is tolerating feeds without problems.