Vivek Bindal, MS, FNB, Ranjan Sudan, MD, FACS. Duke University Medical Center
Intestinal malrotation (IM) occurs once in every 500 births. It can be a challenging situation to deal with while doing an anastomotic bariatric procedure, especially because it is discovered during the preoperative work-up of a bariatric patient. We describe a totally robotic duodenal switch (DS) performed for a patient in whom IM was detected intra-operatively.
The patient was 68 year old with a body mass index of 45 kg/m2. On initial laparoscopic survey, the cecum and terminal ileum was visualized in left mid abdomen. After transection of the duodenum, a hand-sewn loop duodeno-enterostomy was performed at 250 cm from ileo-cecal junction. The alimentary limb was run 150 cm and a hand sewn entero-enterostomy was performed in 2 layers. The normal orientation of alimentary limb (AL) (to the right side) and biliopancreatic limb (BPL) (to the left side) needed to be reversed. The biliary limb was divided near the loop duodeno-enterosotmy to separate the alimentary limb from the biliary limb. Mesenteric defects were closed.
Despite malrotation, a totally robotic BPD-DS was performed using standard five port configuration. A significant technical consideration is the alignment of the distal entero-enterostomy. In the event of malrotation the orientation of the AL and BPL are reversed to prevent internal hernias. Also as the small bowel lies on the right side of the abdomen, the tension on the duodeno-ileostomy is less in BPD-DS as compared to the RYGB, where the GJ has to be created in the left upper quadrant. Understanding these two anatomic principles is important in performing either the RYGB or the BPD-DS in patients with IM.
Robotic DS can be safely performed in IM. Key technical maneuvers include meticulous dissection to identify the anatomy, reversing the orientation of AL and BPL at the entero-enterostomy, tension-free duodeno-enterostomy, and closure of the mesenteric defects.