CASE REPORT Modified circumumbilical approach for duodenal atresia repair : a scarless surgery

Background: Duodenal atresia is a common congenital anomaly causing neonatal intestinal obstruction. The definitive treatment is to restore the intestinal continuity. Laparotomy via upper transverse abdominal incision has been described by many authors as a standard approach for duodenal atresia repair. Here we report a case of newborn underwent duodenal atresia repair via modified circumumbilical approach with satisfactory postoperative outcome. Case presentation: This is a case of premature baby boy, born at 32-week gestation with a birth weight of 1.5kg. Antenatally he was detected to have double bubble sign which was confirmed upon postnatal abdominal radiograph, suggestive of duodenal atresia. He was noted to have a fleshy lump at the umbilicus presumed to be a patent vitello-intestinal duct from the referring hospital. Subsequently he developed umbilical swelling suspicion of umbilical hernia with incarceration and scheduled for emergency umbilical exploration. A circumumbilical incision was made and found to have an umbilical defect with omental herniation, instead of a patent vitello-intestinal duct. A proximal midline incision was made as an extension to the circumumbilical wound enabling a duodenal kocherization and subsequently had duodeno-jejujonostomy anastomosis for the duodenal atresia repair. Postoperative recovery was uneventful with appealing cosmesis. Conclusion: A modified circumumbilical incision is an attractive alternative approach for a duodenal atresia repair. Apart from its cosmetic advantage, the approach provides adequate exposure for similar outcome with transverse abdominal incision.


Introduction
Duodenal atresia is a common congenital anomaly which require surgery during neonatal period to reestablish the intestinal continuity. Transverse upper abdominal incision and use of laparoscopy have been widely described for duodenal atresia repair. In this report, we describe an alternative approach for duodenal atresia repair via a modified circumumbilical incision. This approach has been reported to be comparable with transverse incision for a neonatal laparotomy including for duodenal atresia surgery.

Case report
The boy was born via elective lower section caesarean section (ELLSCS) at 32 weeks with birth weight of 1.5kg for fetal compromise due to abnormal Doppler signals (absent end diastolic flow). Antenatal scans at 24 weeks found a "double bubble" sign. Baby was born vigorous with good Apgar score. Abdominal radiograph confirmed the presence of double bubble sign suggestive of duodenal atresia. He was kept nil by mouth and had umbilical venous catheter (UVC) insertion on the first day of life for a total parenteral nutrition. At day 2 of life, he had a fleshy lump at the base of umbilical stump with some yellowish stained and presumed to be a persistent vitello-intestinal duct. He was transferred to our center and ultrasound abdomen showed an umbilical hernia with bowel content. The umbilical lump appeared swollen and congested on the next day. With a suspicion of incarceration of umbilical hernia, he was brought to theater for umbilical exploration. A circumumbilical incision was performed and noted to have a herniated omentum through a 1cm umbilical defect ( Figure  1). A midline extension over the linea alba was made for a full exploratory laparotomy. Omentectomy was performed, followed by kocherization of duodenum and subsequently underwent duodenojejunostomy with transanastomotic (TA) tube insertion. Postoperatively, the recovery was uneventful. Feeding was started through TA tube and progressed to full feed within a week. At 2 weeks post-surgery, the wound well healed and abdomen appeared scarless except for the gastrostomy site for TA tube ( Figure 2) and he was sent home well. Figure 1. The circumbilical incision allows exterioration of stomach and omentum. The herniated omentum was clamped with Babcock clamp, comparable to its appearance before surgery (as shown in the small box)

Discussion
Gastrointestinal anomalies of the bowel can impact various parts of digestive system. Duodenal atresia is a congenital defect characterized by a abnormal narrow either partial or complete obstruction of the duodenum. This condition occurs in 1 in 10000 live births, affecting boy more frequently.
[1] Surgery is the definite treatment aimed at to restoring the normal flow continuity to enable feeding.
Historically, pediatric surgeons have been using the large transverse incision to access the abdomen for duodenal atresia repair resulting a big scar that grows which may become cosmetically unattractive. A laparoscopic technique also makes it a possible option for surgical intervention via a smaller incision, but the approach is often associated with an longer operative time, more expensive cost, and a significant steep learning curve.
[2] A circumumbilical incision is another attractive option for neonatal laparotomy. It was first reported by Tan and Bianchi in 1986 for pyloromyotomy.
[3] This is a common technique among the pediatric fraternity for certain intrabdominal diseases and was found to be feasible, safe, inexpensive, and virtually scarless. [5] DJ was the first type of repair performed and considered the procedure of choice for many years.
[5] GJ repair technique was not preferred because of the risk of ulceration and malignant transformation due to bilious and pancreatic reflux. DD with a diamond-shaped configuration was described by Kimura et al, which allowed a wider anastomosis for earlier transit of intestinal contents.
[5] Most pediatric surgeons prefer DD, because it is more physiological than DJ. However, surgeons may still perform DJ if the anatomy variant, the birth weight and age of the patient did not suit for DD like in case of preterm birth as in Figure 2: 2 weeks post-surgery, the abdomen appeared scarless except for small scar TA tube wound (as shown with arrow) our case. Up till today there is no literature to suggest that one technique is more superior to the other. [6] Our patient, was known to have duodenal atresia, had abnormal umbilical lesion suspicious of umbilical hernia. Presumably a perforated congenital hernia of umbilical cord, w e d e c i d e d t o e x p l o r e t h r o u g h t h e u m b i l i c u s . Circumumbilical incision is not a routine practice in our center, however the incision was made for the umbilical lesion as it allows to explore the content and with the intention to perform repair and DJ in this patient. Indeed, this approach found to be attractive as it allows surgery to be done comparable to traditional upper transverse abdominal incision with much smaller wound and thus minimal scar formation. However long-term outcome is yet to be uncertain.
This approach is well-suited for operating on the infant's abdomen due to its natural anatomical characteristics. The abdomen of an infant has a limited lengthwise dimension, a relatively thin and flexible abdominal wall, and a comparatively large umbilicus. By manipulating the flexible abdominal wall of the infant, the surgical incision can be positioned precisely over the desired area, without the need to extend it extensively to access distant parts of the abdomen. The elasticity of the skin allows for pulling out the entire bowel, freeing the ascending colon from the retroperitoneum, mobilizing the duodenum, and performing a anastomosis within the surgical field. However, it's important to note that compared to the transverse abdominal or laparoscopic approach, this method has limitations in terms of exploration capability. Additionally, the small opening may pose challenges in accessing organs or masses located outside the peritoneal cavity. Therefore, this approach is recommended only when there is a clear preoperative diagnosis.

Conclusion
The modified circumumbilical approach is an attractive alternative to transverse incision and minimally invasive surgery for a duodenal atresia repair. Apart from cosmetically superior to open operation or even laparoscopy, this approach is safe, feasible and does not require extra equipment or significant learning curve. Ÿ Approach option in approach to duodenel at resia repair can range from small circumbilical to laparoscopic depending on patients size and birthweight Ÿ Circumbilical is an attractive option, but any surgery is always about exposure and control