Robot-Assisted Duodenojejunostomy for Duodenal Stenosis in a 2-Year-Old Child

The patient was placed in the supine position under general anesthesia. After establishment of pneumoperitoneum, robotic ports were inserted under direct vision, and the robotic system was docked.

The duodenum and proximal jejunum were carefully exposed. The stenotic segment of the duodenum and the dilated proximal duodenum were identified. The jejunum was brought into proximity with the dilated proximal duodenum without tension.

An enterotomy was created in the jejunum, and a corresponding opening was made in the proximal duodenum, proximal to the stenotic segment. A linear stapler with an 8-mm stapling cartridge was used to create a side-to-side duodenojejunostomy between the jejunum and the dilated proximal duodenum, thereby bypassing the stenotic segment.

The common enterotomy and staple line were inspected for bleeding, narrowing, leakage, or other technical defects. The common enterotomy was then closed with intracorporeal suturing.

The anastomosis was assessed for patency, hemostasis, and tension. The operative field was irrigated, and the procedure was completed after confirming the absence of active bleeding or anastomotic leakage.

This procedure is indicated for selected patients with congenital or acquired duodenal stenosis causing partial or complete obstruction, particularly when the stenotic segment is unsuitable for primary resection or when a bypass procedure is considered preferable.

Potential indications include:

Symptomatic duodenal stenosis;

Persistent vomiting or feeding intolerance;

Proximal duodenal dilatation associated with distal obstruction;

Obstructive symptoms refractory to conservative management;

Anatomical conditions in which a tension-free duodenojejunostomy can be safely constructed.

The decision should be individualized according to the location and length of the stenotic segment, the degree of proximal dilatation, the patient’s clinical condition, and the surgeon’s experience.

Contraindications or relative contraindications may include:

Hemodynamic instability or inability to tolerate pneumoperitoneum;

Severe cardiopulmonary dysfunction;

Extensive intra-abdominal adhesions that prevent safe robotic access;

Diffuse intestinal disease requiring a different reconstructive procedure;

Inability to mobilize the jejunum to the proximal duodenum without tension;

Suspected intestinal ischemia or perforation;

Severe malnutrition or infection that requires optimization before surgery.

These factors should be evaluated individually. In selected cases, an open procedure may be safer or more appropriate.

The procedure may require the following equipment:

Robotic surgical system;

Robotic camera and 3D visualization system;

Robotic graspers and dissecting instruments;

Robotic bipolar or monopolar energy instruments;

Needle drivers for intracorporeal suturing;

Linear stapler with an 8-mm stapling cartridge;

Absorbable sutures;

Suction and irrigation device;

Standard laparoscopic instruments for assistance;

Nasogastric or orogastric tube, when indicated.

The specific instruments may vary according to the robotic platform, patient size, and surgeon preference.

The patient is positioned supine under general anesthesia. The operating table may be adjusted to provide optimal exposure of the upper abdomen.

The surgical team should ensure adequate access to the upper abdominal cavity. The robotic camera and working ports are placed according to the patient’s body size, abdominal anatomy, and the location of the target structures.

Preoperative evaluation should include a detailed clinical history and physical examination, with particular attention to vomiting, feeding intolerance, abdominal distension, growth status, and previous abdominal surgery.

Recommended investigations may include:

Complete blood count;

Serum electrolytes;

Renal and liver function tests;

Nutritional assessment;

Abdominal ultrasonography;

Upper gastrointestinal contrast study;

Contrast-enhanced computed tomography or magnetic resonance imaging when necessary;

Assessment for associated congenital anomalies.

The upper gastrointestinal contrast study is useful for defining the level and severity of obstruction, the degree of proximal duodenal dilatation, and the passage of contrast into the distal intestine.

Correction of dehydration, electrolyte imbalance, anemia, and nutritional deficiencies should be considered before surgery.

Important anatomical structures include:

The first, second, and third portions of the duodenum;

The stenotic duodenal segment;

The dilated proximal duodenum;

The ligament of Treitz;

The proximal jejunum;

The superior mesenteric vessels;

The pancreatic head;

The transverse colon and mesocolon;

The mesentery of the proximal jejunum.

The anastomosis should be constructed between the jejunum and the dilated proximal duodenum, proximal to the stenotic segment. The jejunal loop should reach the duodenum without tension, twisting, or compromise of its mesenteric blood supply.

Careful attention should be paid to the orientation of the bowel and the relationship between the duodenum, mesentery, and major vascular structures.

No conflicts to disclose