superior mesenteric artery ( sma ) syndrome is defined as a compression of the third portion of the duodenum in between the sma and the aorta .
it is a rare disease that causes many symptoms including postprandial abdominal pain , anorexia , nausea , vomiting , and subsequent weight loss.13 bypass surgery is indicated in patients , when the conservative treatment is failed .
the most common surgical procedure for sma syndrome was laparoscopic duodenojejunstomy.4 herein , the authors report the successful single incision laparoscopic duodenojejunostomy for a patient with an sma syndrome .
a 75-year - old male , 170 cm , 60 kg , presented to our hospital with vomiting for 1 week and 7 kg weight loss for 2 months .
an abdomen computed tomography ( ct ) revealed a severely distended stomach and distal duodenum with obstruction at the level of the sma ( fig .
on ct examination , an aorto - mesenteric angle was narrow to 15 and an aorto - mesenteric distance was short 8 mm ( fig .
after insertion of nasogastric tube , the amount of drainage was more than 2000 cc a day . because of much food in his stomach , esophagogastroduodenoscopy was failed . for 1 week
, the patient was treated conservatively by providing parenteral high caloric nutrition . but the amount of drainage from a nasogastric tube was not decreased ( > 2000 cc / day ) .
the operator stood between patient s legs . on the patient s left side , the first assistant handled the scope .
first , the trans - umbilical 1.5 cm incision was made with the hasson technique .
after making incision , we used a four channel octo - port ( dalimsurgnet , seoul , korea ) .
we made two small incisions at proximal jejunum ( 20 cm from a treitz ligament ) and duodenum ( anterior wall at second portion ) .
and we inserted a 45-mm endo - gia ( covidien , new haven , ct ) in order to create a side - to - side duodenojejunostomy .
one month later , when he visited our clinic , he had gained 6 kg .
sma syndrome was first described in 1861.5 this syndrome is characterized by typical symptoms ( vomiting , nausea , weight loss , and knee - chest position).13 the actual incidence is unknown since the diagnosis is not frequently pursued.4,6 sma syndrome has been associated with prolonged confinement in the supine position , loss of weight , loss of abdominal wall muscle tone , application of a body cast , and severe burns.79 females and young adults are more likely to be affected by the condtion.4,10 our case was a 75-year - old male .
he did not have a past medical history associated sma syndrome ( eg , immobilization , burn , or hidden malignancy ) . and we could not find any abnormality except a distended stomach and duodenum from his ct scans .
radiologic studies ( upper gastrointestinal barium study , angiography , or abdomen ct ) have been established as definitive diagnostic tools for sma syndrome .
. it can show the dilated 1st and 2nd portion of duodenum and the 3-dimensional image of the aorta , sma , and spine . in sma syndrome , the angle between the aorta and sma
is decreased to 625 and a shortened aroto - mesenteric distance of 28 mm.11,12 non - operative treatment is recommended as initial therapy of the sma syndrome .
but , when the conservative treatment has failed , surgery is often required as a curative treatment for sma syndrome .
after the first successful operative treatment , a duodenojejunostomy in 1908,13 sma syndrome has been treated by a laparotomy with duodenojejunostomy .
postoperative sequelae , such as pain and complications , affect not only the patient s general wellbeing but also increase perioperative morbidity and the length of hospital stays .
because of these reasons , laparoscopic surgery , which has the benefits of a small wound , diminished postoperative pain , and decreased hospital stay has been widely accepted and is used for treatment of many diseases .
advances in laparoscopic skills and instruments have enabled surgeons to perform a laparoscopic surgery . in 1998 , gersin performed the first laparoscopic duodenojejunostomy for treatment of sma syndrome.14 nowadays , the most common surgery for sma syndrome is a laparoscopic duodenojejunostomy.4 furthermore , a reduced port or single incision laparoscopic surgery ( sils ) has been adapted for benign disease.1517 however , the introduction of sils , sils is not widely performed except a cholecystectomy , appendectomy , or gynecologic surgery.1517 sils has longer operative time and more difficulties than conventional laparoscopic surgery.1619 there were several case reports about 
laparoscopic duodenojejunostomy for sma syndrome.4,10,20,21 most of them reported a good surgical outcome or success.4,10,20,21 a conventional laparoscopic duodenojejunostomy ( three to four ports ) took 1 hour and 35 minutes to 3 hours.20 in this regard , our operation time ( 3 hours ) was not longer than these .
a duodenojejunostomy is a simple procedure that makes an anastomosis for bypass and the loss of his visceral fat made us easily identify a dilated duodenum and a proper surgical plane .
so we decided to perform a sils approach instead of a conventional laparoscopic approach.1619 it is true that sils is ergonomically more stressful for the surgeon than the standard laparoscopic approach .
some reports about sils have failed to demonstrate the superiority to conventional laparoscopic approach ( eg , cosmesis , wound pain , and surgical site infection).22,23 but there were several reports that favored sils.15,16,24,25 the surgical instrumentation and techniques have been improved . thereby , the sils approach will be more convenient for surgeons , and this approach may be beneficial for selected cases . in this report
, we describe the first known case , to our knowledge , of single incision laparoscopic duodenojejunostomy for sma syndrome .
 superior mesenteric artery ( sma ) syndrome is a mechanical duodenal obstruction by the sma . 
 the traditional approach to sma syndrome was open bypass surgery . 
 nowadays , a conventional approach has been replaced by laparoscopic surgery . but 
 single incision laparoscopic approach for sma syndrome is rare . 
 herein , we report the first case of sma syndrome patient who was treated by single incision laparoscopic duodenojejunostomy . 
Introduction
Case Report
Discussion