Pyloromyotomy
Infants with hypertrophic pyloric stenosis typically develop symptoms in the first month or two of life. The history of progressive nonbilious vomiting, occurring right after feeding, is classic. Palpation of a rounded “olive” in the epigastrium is diagnostic, and this may be confirmed by ultrasound examination. The treatment is myotomy. Both open and laparoscopic techniques are available. This chapter explores both.
Hypochloremic hypokalemic metabolic acidosis is a characteristic. Always correct the associated dehydration and electrolyte abnormalities before performing either of these procedures.
SCORE™, the Surgical Council on Resident Education, classified pyloromyotomy as an “ESSENTIAL UNCOMMON” procedure.
STEPS IN PROCEDURE
Open Pyloromyotomy (Ramstedt Procedure)
Umbilical or right upper quadrant transverse incision
Deliver hypertrophied pylorus into incision
Longitudinal incision along anterior wall of thickened portion
Spread and divide all circular muscle fibers using pyloromyotomy spreader
Confirm that submucosa pouts out and that it is intact
Close incision
Laparoscopic Pyloromyotomy
Trocars at umbilicus, left and right upper quadrants
Pass atraumatic grasper through right upper quadrant trocar; sweep liver cephalad and grasp duodenum just below pylorus
Make incision on anterior surface of thickened portion of pylorus using laparoscopic pylorotome
Use laparoscopic spreader to split hypertrophied fibers
Confirm adequate myotomy and absence of perforation
HALLMARK ANATOMIC COMPLICATIONS
Inadequate myotomy
Perforation (usually at the duodenal end of the myotomy)
LIST OF STRUCTURES
Stomach
Duodenum
Pylorus
Liver
Open Pyloromyotomy (Ramstedt Procedure) (Fig. 67.1)
Technical and Anatomic Points
Make a small incision in the umbilical fold or a short transverse right upper quadrant incision. Reach in, palpate, and deliver the thickened pylorus. Make a longitudinal incision over the anterior surface of the thickened portion. Deepen this incision through the hypertrophied circular fibers. A special spreader assists in opening the myotomy to display the herniated submucosa. Carry the myotomy from the stomach down onto the duodenum, taking care not to injure the mucosa. Perforation is most likely to occur at the duodenal end, because the duodenum is thinner than the stomach. The myotomy must completely divide all fibers of the hypertrophied pylorus.
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