A neonate born at 38 weeks presents with bilious vomiting and abdominal distension on day 2. X-ray shows a double-bubble sign without distal gas. What is the most appropriate surgical procedure?

• A Ladd's procedure for malrotation with volvulus
• B Pyloromyotomy for pyloric stenosis
• C Diamond-shaped duodenoduodenostomy for duodenal atresia ✓
• D Ileostomy for jejunal atresia

Explanation

The double-bubble sign (dilated stomach + dilated proximal duodenum) with complete absence of distal gas on plain X-ray is pathognomonic of duodenal atresia. The standard repair is a diamond-shaped duodenoduodenostomy (anastomosis between proximal and distal duodenum, with transverse incision in proximal duodenum and longitudinal incision in distal). Ladd's procedure is for malrotation/volvulus (which typically shows proximal dilation but may have some distal gas). Pyloric stenosis does not cause bilious vomiting. Jejunal atresia causes more distal obstruction with multiple air-fluid levels.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.