Chapter 1 of 5 · Case-Based Learning
Case setup
Case presentation and patient positioning
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Host summaries · secondary, not cited in answers
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
A newborn with prenatal diagnosis of bowel obstruction was found to have jejunal atresia on upper GI study
The surgeon stands at the baby's feet with the cameraman on the baby's right and the scrub tech on the patient's left for this procedure
A 3-port technique was used with a 4 mm 30-degree scope for visualization and two 3 mm ports for dissection
The left mid-quadrant port was later changed to a 5 mm port for the stapler
The Veress needle is inserted below the umbilicus to avoid injury to the umbilical vessels and prevent CO2 embolism
There was a complete gap between the proximal jejunum and the distal bowel, with visualization of appendix and cecum suggesting an apple peel defect
The bowel was run from proximal to distal to ensure there were no other areas of obstruction or kinking
Running the bowel distally confirmed an apple peel defect, as the bowel could be seen twisting around the mesentery
Because there was no evidence of a kink or significant obstruction, the mesentery was not further manipulated
A decision was made to remove the proximal dilated segment in the hopes of improving bowel motility following surgery, because it was relatively short and significantly dilated
The mesentery is taken down using a 3 mm bipolar vessel sealer, with vessels clamped, sealed, and then teased off the mesenteric border of the bowel
The dissection was carried back almost to the ligament of Treitz and encompassed approximately 10 cm length of bowel
A 5 mm endoscopic stapler was used to divide the bowel, laying down 4 rows of staples and dividing between them
Two applications of the stapler were required because the bowel was so dilated, with a diameter of almost 4 cm
The distal jejunal segment was anastomosed to the proximal dilated segment in an end-to-side fashion
An enterotomy was made in the proximal dilated bowel using a 3 mm hook cautery and then decompressed with a 3 mm sucker
An upper GI obtained one week postoperatively showed a widely patent anastomosis
The resected specimen measured 10 cm
A similar enterotomy was made in the distal jejunal segment and slightly dilated to allow access of the stapler
The anastomosis was approximately 2.5 cm in length
The resultant enterotomy was closed with a running absorbable suture
Previous to having the stapler, an end-to-end anastomosis would have been performed with multiple interrupted or running sutures
After completion of the enterotomy, there was no evidence of significant mesenteric defect or any gap in the anatomy
The procedure took 80 minutes and was tolerated well by the infant
The patient had diminishing NG aspirates over the next week