Natural orientation-based parallel anastomosis in laparoscopic duodenoduodenostomy: association with atresia location and perioperative outcomes in a retrospective cohort study

Purpose: At our institution, congenital duodenal atresia is repaired laparoscopically using duodenoduodenostomy with a parallel anastomosis. During our use of this technique, we noted that after mobilization, the distal duodenal segment naturally rested in either a cranial or caudal orientation relative to the proximal segment and that this resting orientation appeared to vary with the anatomical level of atresia. This study primarily evaluated the association between atresia location and the natural orientation of the distal duodenal segment. It secondarily compared perioperative outcomes between the cranial and caudal orientation groups. Methods: This retrospective cohort study was conducted at Samsung Medical Center (Seoul, South Korea) and included neonates who underwent laparoscopic duodenoduodenostomy with parallel anastomosis for congenital duodenal atresia from January 2008 to June 2021. After patients with annular pancreas or duodenal web were excluded, 22 neonates were analyzed and categorized into the cranial (n=16) or caudal (n=6) orientation group according to intraoperative findings. Perioperative outcomes were compared, and the relationship between atresia location and distal segment orientation was analyzed. Results: Operative time, postoperative ventilator support, time to feeding initiation, time to full feeding, and length of hospitalization did not differ significantly between groups. No patient required conversion to open surgery, developed an anastomotic stricture, or died during hospitalization. One patient in the cranial group developed an anastomotic leak, which was treated by laparoscopic reanastomosis. First-portion duodenal atresia was significantly more frequent in the caudal group than in the cranial group (83.3% vs. 25.0%, P=0.023). Conclusion: Laparoscopic duodenoduodenostomy with parallel anastomosis was feasible in both cranial and caudal orientations, with no conversions to open surgery. The natural orientation of the distal duodenal segment was significantly associated with the anatomical location of atresia, supporting an anatomical basis for orientation-guided parallel anastomosis.