Fig. 23.1.
Port placement—while the s urgeon stands at the feet of the patient, the port is placed directly through the umbilicus. Following insufflation, a right subcostal stab incision is made just inferior to the liver border to provide access for the duodenal grasper and a similar incision to the left of the midline in line with the greater curve of the stomach through which the pyloric spreader and electrocautery may insert.
Fig. 23.2.
(a) Exposure of the pylorus is obtained. The surgeon takes a solid bite across the duodenum, just distal to the pylorus with the left-hand grasper. (b) Using the cutting setting, a transverse seromuscular incision is made from the junction of the pylorus and the duodenum proximally to the gastric antrum. (c) The pyloric spreader is inserted in the seromuscular incision and opened slowly with a steady pressure to separate the pylorus muscle. (d) Mucosal lining is observed to extrude from the incision.
If there is no evidence of a perforation, the instruments are removed from the stab incisions, and the abdomen is desufflated through the umbilical trocar. The fascia at the umbilical port should be closed. If the stab incisions were not over dilated, they do not need a fascial closure. The skin from the stab incisions can be approximated with Steri-Strips (3M Company, St. Paul, MN) or Dermabond (Ethicon, Cincinnati, OH).
In the event of a duodenal or mucosal perforation, the surgeon should close the pyloromyotomy and create a new pyloromyotomy incision on the opposite side. Some have reported success with a primary mucosal repair with or without an omental patch [24, 25]. This may require conversion to an open technique depending upon the surgeon’s experience and preference.
Pearls/Pitfalls
When grasping the duodenum, it is important to get a large bite across the duodenum, as small bites can cause traumatic perforations to the thin-walled duodenum.
When placing the left-sided (right hand) stab incision, it is better to line it up with the lower edge of the pylorus. If this incision is made too high, it is an awkward angle to perform the pyloromyotomy .
Make the pyloromyotomy on the most avascular surface of the pylorus. This sometimes requires the pylorus to be rolled down slightly.
If having difficulty getting the pyloric spreader in the myotomy, gain access with just one of the grasper arms and gently twist to create a wider area. Then replace both arms of the grasper in the muscular space for spreading the myotomy open.
Most perforations occur at the duodenal end of the myotomy where the mucosa becomes shallow quickly.
Most incomplete myotomies occur at the gastric end [25].
Stab incisions do not need to have a fascial closure, unless they have been over dilated. If omentum is herniating out of a stab incision, consider closing the fascia [26].
Postoperative Care
The infants can be fed ad lib in the recovery room, when they are awake enough to eat. The majority of patients will have postoperative emesis, but if the child is fed through this, it usually resolves within 48–72 h [27–29]. Studies have shown that while there is little to no difference with operating time or time to full feeding, infants undergoing laparoscopic repair have better pain control requiring fewer doses of analgesic medications, they experience fewer episodes of postoperative emesis, and scarring is reportedly more cosmetically appealing [27, 28]. Postoperative pain is minimal and can be controlled with acetaminophen. Narcotics should be avoided. Infants should remain monitored during the immediate postoperative period given the elevated risk of postoperative apnea present as a result of young age, prematurity, or preoperative alkalosis.
With regard to length of hospital stay, studies either show no difference or shorter length of stay with laparoscopy. Rate of perforation is approximately the same regardless of open or laparoscopic technique. Mucosal perforations, regardless of technique, are seen in less than 1 % of infants undergoing pyloromyotomy . In contrast to open technique, incomplete pyloromyotomy rate is slightly higher with laparoscopic approach; nonetheless, incomplete pyloromyotomy is only seen in 3–5 % of patients treated laparoscopically. Wound complications such as infection and dehiscence are seen more frequently in those undergoing open pyloromyotomy as compared to laparoscopic [28, 29].
Summary
Hypertrophic pyloric stenosis is a disease of infancy, typically diagnosed between 3 and 5 weeks of age and characterized by worsening projectile, non-bilious emesis secondary to gastric outlet obstruction from progressive hypertrophy of the pylorus muscle.
Etiology is unclear but can be described as multifactorial with some genetic predisposition.
This disorder affects boys more often than girls as well as premature more often than term infants.
Classically described presentation includes: progressively worsening immediate postprandial non-bilious projectile or forceful emesis, difficulty with weight gain or drop on the growth curve, signs and symptoms of dehydration, a palpable “olive-mass” on physical exam, and a hypochloremic hypokalemic metabolic alkalosis with paradoxical aciduria.
Ultrasonography is >95 % sensitive and specific for diagnosis of hypertrophic pyloric stenosis; however, this varies depending on technician skill and experience.
Radiographic criteria for diagnosis includes: a pyloric muscle thickness >3 mm and a pyloric muscle length >15 mm. Lack of gastric contents traversing the pyloric channel also supports a diagnosis of pyloric stenosis.
Upon diagnosis of hypertrophic pyloric stenosis, surgical therapy is indicated.
Preoperative rehydration should be completed with normal saline 20 cc/kg boluses until there is urine output, followed by IV fluid hydration at a rate 1.5× maintenance with D5W 0.45 % normal saline with 20 mEq KCl until bicarbonate level is less than 30 mEq/L.
Pyloromyotomy is completed as follows: a seromuscular incision is made from the junction of the pylorus and duodenum to the gastric antrum and then opened slowly with the pyloric spreader until mucosal lining is seen and the two halves are observed to move independently of each other.
In the event of duodenal mucosal perforation, the perforation should be closed primarily and a new pyloromyotomy incision should be made on the opposite side.
Postoperative care involves adequate analgesia, monitoring for postoperative apnea, and initiation of ad-lib oral feeding. Regurgitation is common in immediate postoperative period and should not delay feedings.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
