The Experimental Studies And Clinical Applications Of Laparoscopic Single-layer Sutured Anastomosis For The Digestive Tract Reconstruction In Children

Objective: The deformation of the digestive tract is the most common disease in pediatric abdominal surgery. It is corrected by the operation as early as possibly. The laparotomy is used as its conventional treatment procedure in the past. The normal growth and development of children is often influenced due to its big incision, organic exposure and complications. The mini-invasive characteristics of laparoscopy maybe decrease the operative morbidities and enhance the treatment effectiveness. However, the most crucial part of the laparoscopic procedure for the digestive malformation is likely to reconstruct the alimentary tract related to the precise sutured anastomosis. Therefore, the aim of this study was to explore the reliable methods of a laparoscopic single-layer duodenal and biliary-enteric sutured anastomosis through animal experiments and utilize the clinical works.Methods:1 Animal experiment:The ten rabbits (weight arranged, 3-4 kilograms) were pretended to simulate the abdominal environment of newborn and infant. They were randomly divided into the continuous suture group and the interrupted suture group to carry out the single-layer diamond-shaped anastomosis in the duodenum. Under the laparoscope, the duodenum was ligated with 2-0 silk as the obstructive animal model through 3 trocar technique. A transverse incision in the proximal duodenum and a distal longitudinal incision adjacent to the obstruction were done with the electric hook. A diamond-shaped anastomosis was performed with 5-0 Vicryl in the form of full-thickness interrupted suture in a group. In another group, the posterior and anterior full-thickness continuous suture were respectively anastomosed. The operation time of two groups was recorded, the caliber and patency of anastomosis were observed with laparotomy, the tolerant pressure of the anastomosis was measured with methylene blue solution perfusion after blocking on both sides of anastomotic duodenum.Statistical evaluation was performed using SPSS 13 for Windows. The data were analyzed the t student test. A p value of less than 0.05 was considered significant.2. Clinical application: According to the results of animal experiment, the single-layer full-thickness sutured anastomosis was applied in 11 cases with congenital duodenal obstruction and 20 cases congenital choledochal cyst from January 2008 to February 2010. The patients with congenital duodenal obstruction had underwent laparoscopy with 3 trocar technique, the cause of duodenal obstruction was explored and a single-layer diamond-shaped sutured anastomosis was performed after the duodenum incised under the laparoscopic vision. The laparoscopic choledochal cyst surgery were attempted using 4 cannulas, the total excision was carried out under intraoperative cholangiopancreaticographic guidance, the Roux-en-Y jejunojejunostomy was performed extracorporeally by exteriorizing the jejunum through the extending umbilical incision, and an retrocolic end-to-side hepaticojejun -ostomy was completed with the hand-sewn full-thickness continuous suture intracorporeally. Data about operative time, surgerical technique, perioperative complications and follow-up problems were recorded.Results:1 Animal Experiment: All laparoscopic single-layer diamond-shaped anastomoses of the duodenum were successfully performed in 10 rabbits. The hand-sewn anastomotic time was 38.8±5.07min(32~42min) in the interrupted suture group and 27.0±7.25min(19~36min) in the continuous suture group, the continuous suture time took shorter than the interrupted suture time and it was statistically significant(t=2.984, p=0.017, p<0.05). The laparotomy after laparoscopic procedure in two groups of rabbits showed good patency of the anastomosis and no intestinal leakage. The average circumference of the anastomosis was 1.99±0.14cm in the interrupted suture group and 1.92±0.06cm in the continuous suture group, showing no significant difference between the two groups(t=1.016, p=0.34, p>0.05). The tolerant pressure of the anastomosis was 72.4±19.50cmH2O in the interrupted suture group and 90.8±6.38cmH2O in the continuous suture group. The significant difference wasn't found between the two groups(t=2.00, p=0.08, p>0.05). However, there was a rabbit that the pressure could only meintain 48cmH2O due to interrupted anastomotic mucosal eversion.2 Clinical Research: The etiology of 11 children was laparoscopically identified and all procedures were successfully performed, no one case was converted to open. Six cases with duodenal diaphragmatic stenosis were encountered a partial excision of the diaphragm after vertical incision of the anterior part in the duodenum followed by a transverse suture. A diamond-shaped full-thickness duodenoduodenal anastomosis was completed in 3 cases with duodenal atresia and 2 annular pancreas. The operative time of duodenal obstruction was 60 ~ 150min. All of 20 children with laparoscopic total cyst excision and Roux-en-Y hepaticojejunostomy were completed under the intraoperative cholangiographic guidance. The operative time of choledochal cyst was 170~250min. There was no intraoperative complications and blood transfusion. Except 1 neonate with transient anastomotic leak was cured by draining for 3 days (from day 2 to 4 postoperatively) without another intervention, feedings were started on postoperative day 3 to 6. All cases were cured and the postoperative period of hospital stay was 7 to 12 days. Only one case with typeⅣcyst required reoperation duo to developed hepaticojejunal anastomotic stricture after primary laparoscopy. All children were symptom free with a normal growth and the cosmetic result was good during the follow-up period.Conclusion : Animal experiments concluded as follows :①The hand-sewn single-layer anastomosis of digestive tract is carried out that it avoids mucosal eversion. If the mucosal eversion occured, the anastomotic tolerant pressure would decrease significantly and prone to anastomotic leakage.②The single-layer interrupted and continuous suture anastomosis could achieve satisfactory effect together, but the continuous suture is more convenient and time-saving comparing with the interrupted suture under the laparoscope. Based on these experimental conclusions, the laparoscopic single-layer sutured anastomosis applied in the digestive tract reconstruction is a safe and reliable procedure with minimally invasive approach, earlier discharge from the hospital and a better cosmesis.