Surg Endosc
DOI 10.1007/s00464-016-5241-y
Laparoscopic duodenoduodenostomy with parallel anastomosis
for duodenal atresia
Chaeyoun Oh1 • Sanghoon Lee2 • Suk-Koo Lee2 • Jeong-Meen Seo2
Received: 7 August 2016 / Accepted: 6 September 2016
Ó Springer Science+Business Media New York 2016
Abstract
Background Currently, a diamond-shaped anastomosis is
preferred for the surgical repair of duodenal atresia (DA) in
both open and laparoscopic surgery. We report the results
of laparoscopic duodenoduodenostomy with parallel anas-
tomosis (LDPA) in DA.
Methods We retrospectively reviewed 22 patients who
underwent laparoscopic duodenoduodenostomy from
February 2005 to May 2015 in Samsung Medical Center.
All patients underwent operation within the first month
after birth. Patients who were transversely anastomosed
after duodenotomy and patients who underwent simulta-
neous operation on combined anomalies were excluded.
Parallel anastomosis was used in all surgeries. Four trocars
were used in laparoscopic repair. After mobilization of
both proximal and distal ends, the proximal end was
incised transversely and the distal end was incised longi-
tudinally. Duodenoduodenostomy with parallel anastomo-
sis using a 5-0 glyconate monofilament was performed with
interrupted sutures.
Results Eleven patients (50 %) were male. Median gesta-
tional age was 36 ? 6 weeks (32 ? 7–40 ? 6). Median
age at the time of operation and median body weight were
3 days (1–12) and 2.53 kg (1.63–3.18), respectively. All
patients were diagnosed prenatally and 16 patients
(72.7 %) had associated anomalies. Median operation time
& Jeong-Meen Seo
jm0815.seo@samsung.com
1
Department of Pediatric Surgery, Seoul National University
College of Medicine, Seoul, Korea
2
Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine, 81 Irwon-ro,
Gangnam-gu, Seoul 06351, Korea
and Other Interventional Techniques
was 142 min (96–290) and median postoperative day to
start oral feeding was 5 days (3–9) and median postoper-
ative day of reaching full feeding was 11 days (6–19).
Median postoperative day was 13 days (10–60). There was
no anastomotic leakage or stenosis. Median follow up was
3.5 months (1–21). Currently, there is no late complication.
Conclusions LDPA can be performed easily to patients
who have DA in neonatal period. It is anatomically natural
and the risk of leakage or stenosis does not seem signifi-
cant. Therefore, parallel anastomosis should be considered
as a safe procedural option for laparoscopic duodenoduo-
denostomy in DA.
Keywords Laparoscopic duodenoduodenostomy

Duodenoduodenostomy
Parallel anastomosis
Duodenal
atresia
Diamond-shaped anastomosis
Duodenal atresia is the main cause of congenital duodenal
obstruction and occurs once in every 10,000 live births [1, 2].
More than 50 % of DA patients have combined anomalies
[2–4]. In 1932, Ladd et al. [5] reported the first surgical
correction of DA. Until the 1970s the standard procedure for
anastomosis of DA was duodenoduodenostomy or duode-
nojejunostomy with a parallel anastomosis [6–10]. In 1969,
Fonkalsrud et al. [1] reported that the mortality rate of DA
and stenosis was 32 %, and that half of these mortalities were
related to anastomotic complications. In 1977, Kimura et al.
[11, 12] introduced a new approach using a diamond-shaped
anastomosis that has since been utilized by many centers.
Even after the introduction of laparoscopic repair of DA by
Bax et al. [13] in 2001, the diamond-shaped anastomosis is
still considered the gold-standard procedure [14–17]. How-
ever, there is insufficient literature on laparoscopic duo-
denoduodenostomy with parallel anastomosis (LDPA). In
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 Surg Endosc

our center, we routinely perform LDPA and have found this

procedure to be easy to perform and also more anatomically
natural compared to the diamond-shaped anastomosis.
Herein we report the results of LDPA with low rates of
postoperative anastomosis leakage or stenosis.

Materials and methods

We retrospectively reviewed 22 patients who underwent

laparoscopic duodenoduodenostomy from February 2005 to
May 2015 in Samsung Medical Center. All patients were
confirmed to have DA in the operating field. Patients with
DA who underwent duodenoduodenostomy in their first
month of life were included. Patients who underwent trans-
verse anastomosis after longitudinal duodenotomy and
patients who underwent operations for combined anomalies
simultaneously with duodenoduodenostomy were excluded.
The study included 22 patients who underwent laparoscopic
repair involving duodenoduodenostomy with parallel anas-
tomosis. Patient data including sex, gestation age, prenatal
diagnosis, associated anomalies, body weight and age on the
day of surgery, operating time, postoperative hospital course
and perioperative complications were collected.
The laparoscopic technique was as follows. Patients
were positioned at the end of the operating table. The
operator stood on the caudal side of the patient while the
scopist stood on the left side of the operator and the scrub
nurse stood on the right side of the operator. The monitor
was placed in front of the operator. Four trocars were
inserted: a transumbilical camera port (5 mm), two work-
ing ports (3 mm) on either side of the umbilicus, and one
assistant’s port (3 mm) on the epigastric area (Fig. 1).
After dissecting the distal portion of the stomach, the
proximal end of the dilated duodenum can be identified.
The distal duodenal end of the atretic portion can be
identified with a retroperitoneal approach. After dissection,
most cases showed a natural alignment as illustrated in
Fig. 2A. It is important to make both sides redundant to
minimize possible tension on the anastomosis before
opening the duodenum. At this time, a lumbar puncture
needle (22 gauge) is percutaneously inserted into the distal
bowel to inject saline into the distal bowel and confirm
distal passage. A seromuscular tagging suture was made on
both tips of the planned anastomosis site to fixate the bowel
during the procedure. The bulbous proximal duodenum
was opened with an endoscissor transversely on the distal
part of the anterior wall. The distal duodenum was opened
longitudinally. The incisions are parallel because of the
perpendicular alignment of proximal and distal duodenum.
The incisions are made as long as possible to avoid
stenosis. Interrupted sutures using 5-0 glyconate monofil-
ament (Monosyn, B Braun, Melsungen, Germany) were
Fig. 1 Port placement and position of the operating staff
performed on the posterior wall. The first suture on the
upper edge of the posterior wall is retracted upper and
ventrally by the assistant to facilitate further procedures.
The anterior wall is subsequently anastomosed with inter-
rupted sutures. A transanastomotic tube is not routinely
inserted (Fig. 2).
We routinely try to identify the duodenal papilla but this is
not possible in all cases. When the papilla is seen through the
longitudinal incision on the distal bowel segment, much care
is taken not to injure the papilla during anastomosis. In cases
where the papilla is not readily identified, no further attempts
are made to locate the structure.
The patient is monitored postoperatively in the neonatal
intensive care unit. Feeds are initiated when passage of gas
into the small intestines are observed on abdominal
radiograph and drainage from the nasogastric tube is less
than 5 cc/kg/day. 10 cc per feed of breast milk or formula
is given at first and then built up by 10 to 20 cc/day until
the patient reaches full feeds.
This study was approved by the Institutional Review
Board at Samsung Medical Center (IRB File No. 2015-07-
006-003).
Results
There were 11 (50.0 %) male patients. Median gestational
age was 36 ? 6 weeks, median birth weight was 2.72 kg,
median age at the time of operation was 3 days and median
body weight at the time of operation was 2.53 kg. The

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Surg Endosc

Fig. 2 Operative procedure of

laparoscopic
duodenoduodenostomy with
parallel anastomosis. A Stay
suture on both edges of
proximal and distal ends.
B Approximation of both ends.
C Transverse incision on
proximal end and longitudinal
incision on distal end.
D Interrupted suture with full
layer of the posterior wall.
E Interrupted suture of the
anterior wall

proportion of patients with combined anomalies was Table 1 Characteristics and outcomes of the patients
72.7 %. Combined anomalies were 6 patients with Down’s
Details Value
syndrome, 11 cardiac anomalies, 1 brain anomaly, 1
imperforate anus, 1 Hirschsprung’s disease, 1 laryngoma- Male 11 (50 %)
a
lacia, 1 tracheomalacia, and 3 limb anomalies (Table 1). Gestational age (weeks ? day) 36 ? 6 (32 ? 7–40 ? 6)
None of the cases were converted to open repair. Median Birth weight (kg)a 2.72 (1.75–3.24)
operation time was 142 min. Median time of first stool Age at the time of operation (days)a 3 (1–12)
passage was postoperative 3 days and first oral feeding was Body weight at operation (kg)a 2.53 (1.63–3.18)
postoperative 5 days. Median time to reach full oral feeding Associated anomaly 16 (72.7 %)
was 11 days. Median postoperative hospital stay was Operative time (minutes)a 142 (96–290)
13 days and median follow-up period was 3.5 months. Postoperative ventilator daysa 0 (0–22)
All patients were diagnosed prenatally. One patient who Postoperative hospital daysa 13 (10–60)
was discharged 60 days after LDPA underwent operation Time to first stool passage (days)a 3 (1–10)
for cardiac anomaly on the 28th postoperative day and Time to first oral feeding (days)a 5 (3–9)
operation for Hirschsprung’s disease on the 52nd postop- Time to reach full oral feeding (days) a
11 (6–19)
erative day. One case of postoperative complication Follow up (months)a 3.5 (1–21)
occurred: tension pneumothorax that resolved after con- a
Median
servative management. There was no anastomotic leakage
or stenosis. No late complications were seen during the
postoperative follow-up period.
although DA can also be confirmed with the typical dou-
ble-bubble sign with gasless abdomen in a plain radiograph
Discussion taken after birth [2].
The mortality rate was 40 % when Ladd et al. first
DA is one of the main causes of emergent surgery in the reported their surgical repair of DA; however, it has
neonatal period. A delay in diagnosis and operation can dropped to 5–10 % with improvements in neonatal inten-
lead to aspiration pneumonia and malnutrition. Currently, sive care, parenteral nutrition, operative techniques and
most cases are diagnosed prenatally with ultrasonography, management for combined anomalies. Currently,

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Table 2 Studies of laparoscopic duodenoduodenostomy for congenital duodenal obstruction
References Number Body weight at the
time of operation (kg)
Spilde et al. [25] 15 3.224 ± 1.54
Kay et al. [15] 17
Hill et al. [23] 22 2.5 (1.6–8.5)
Li et al. [22] 40 3.1 (2.4–3.5)
Jensen et al. [16] 20 2.56 (1.74–3.44)
Present study 22 2.53 (1.63–3.18)
mortalities seen in DA are mostly due to combined
anomalies [18].
Laparoscopic surgery is considered to be superior to
open laparotomy in visualization, bowel assessment,
cosmesis and postoperative adhesions [19]. The boundaries
of pediatric laparoscopy have been widened markedly over
the last 2 decades. Although many surgeons investigated
the practicability of laparoscopic repair of DA after the first
report in 2001, the results were disappointing with abun-
dant postoperative leakage [17]. In 2007, anastomosis
using a U-clip was first reported as a solution [20]. How-
ever, with improvements in laparoscopic techniques
including intracorporeal suturing, many surgeons began
reporting similar leakage rates and superior recovery
compared to open laparotomy [15–17, 21–23].
Before the 1970s, anastomosis of DA was usually per-
formed side-to-side. However, blind loop syndrome and
anastomotic stenosis or leakage frequently occurred and
were considered to be related to the bowel function on the
anastomotic site [1]. In 1977, Kimura et al. [11] reported
their diamond-shaped anastomosis with a larger stoma and
claimed that the recovery of bowel function was faster with
their method of anastomosis. In their report published in
1986, Weber et al. [24] compared various types of duo-
denoduodenostomies and concluded that a diamond-shaped
anastomosis was related to earlier feeding and discharge.
However, a diamond-shaped anastomosis requires more
dissection of the distal duodenal stump and usually results
in abnormal morphology [12].
In our study, we wanted to point out the usual perpen-
dicular alignment of the proximal and distal bowels
(Fig. 2A). With a transverse incision on the proximal end
and a longitudinal incision on the distal end, duoden-
oduodenostomy with parallel anastomosis is possible. An
advantage of the parallel anastomosis is that it is possible to
anastomose the proximal and distal segments with minimal
dissection and mobilization because the two atretic seg-
ments are usually aligned in a perpendicular configuration.
Moreover, the duodenum can remain positioned in the
retroperitoneum with a natural C-loop shape after com-
pletion of the anastomosis. We consider this more
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Surg Endosc
Time to first oral Time to reach full Postoperative Stenosis
feeding (days) oral feeding (days) hospital days or stricture
5.4 9 12.9 1 (6.7 %)
8 (3–18) 12 (5–28) 0
7 (0–36) 0
3–7 9–14 1 (2.5 %)
10 (4–44) 15 (6–72) 1 (5 %)
5 (3–9) 11 (6–19) 13 (10–60) 0
anatomically natural than a diamond-shaped anastomosis,
which requires the lower end of the distal longitudinal
incision to reach the midpoint of the proximal incision.
Minimal dissection around the duodenum and surrounding
structures should be practiced whenever possible during
surgical procedure on a neonate.
Functional outcomes of our LDPA were comparable to
previous published reports of laparoscopic DA repair using
various anastomosis techniques. As in other published
studies, we started feeding with consideration of the amount
of drainage from the nasogastric tube and the gas pattern in
plain radiography. Among five published studies of laparo-
scopic repair for congenital duodenal obstruction that were
published after 2008, four [15, 16, 22, 25] performed dia-
mond-shaped anastomosis and one study [23] did not
describe the type of anastomosis. These studies showed
similar results to our study regarding first oral feeding and
time taken to reach full oral feeding (Table 2). Also, we have
not encountered postoperative anastomotic stenosis after
LDPA. Previous studies have reported 0–6 % rate of stenosis
or stricture at the anastomosis site, as shown in Table 2.
Leakage and stenosis are the greatest concerns in bowel
anastomosis. Although it has been reported that interrupted
suture is associated with less stenosis and more leakage
compared to continuous suture, there is insufficient sup-
porting evidence [26, 27]. One study reported no leakage in
laparoscopic duodenoduodenostomy after changing from
interrupted suture to continuous suture [17]. In our study,
there was no leakage despite the use of interrupted sutures.
Although the use of interrupted sutures is more time-con-
suming, with an improvement in operating skills (such as
intracorporeal suture technique and identification of full-
layer suture) the operating time can be reduced. The last
procedure mentioned in our study was completed in
96 min. The authors have performed 13 cases of open
duodenoduodenostomy for congenital DA. The operation
time of open duodenoduodenostomy ranged from 47 to
125 min, with a median operation time of 74 min.
A limitation of this study is that we did not compare
LDPA with laparoscopic duodenoduodenostomy with dia-
mond-shaped anastomosis. A prospective randomized trial
Surg Endosc
will be necessary to further assess the benefit of this
procedure.
Conclusion
LDPA can be safely performed in neonates with congenital
DA. It is anatomically natural and the risk of leakage or
stenosis appear comparable to laparoscopic duodenoduo-
denostomy with diamond-shaped anastomosis. Therefore,
parallel anastomosis may be considered as a procedural
option for laparoscopic duodenoduodenostomy in DA.
Compliance with ethical standards
Disclosures Dr. Chaeyoun Oh, Dr. Sanghoon Lee, Dr. Suk-Koo Lee
and Dr. Jeong-Meen Seo have no conflicts of interest or financial ties
to disclose.
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