Chapter 87 Pyloromyotomy
INTRODUCTION
Infantile hypertrophic pyloric stenosis (HPS) is a common condition of infancy that is easily corrected by surgery. The overall annual incidence ranges from 8.2 to 12.3 cases per 1000 live births.1 The classic presentation is that of nonbilious, projectile vomiting in a 2- to 8-week-old newborn. The vomiting results in a contraction alkalosis secondary to severe dehydration. Sonographic identification of a thickened and lengthened pylorus helps to solidify the diagnosis. The “gold standard” of treatment is the open pyloromyotomy described by Fredet in 19082 and modified by Ramstedt in 1912.3 An overall complication rate of 10% (4% intraoperative and 6% postoperative) has been reported, with complications including duodenal mucosal perforation, wound infection,4 and postoperative vomiting.5
Eighty years after the conventional open procedure was introduced, laparoscopic pyloromyotomy (LPM) was described.6,7 Over the ensuing years, the minimally invasive approach has gained widespread use and acceptance. Complication rates of 3% to 18% have been reported for LPM.8–11 These complications have included mucosal perforation, incomplete pyloromyotomy, serosal laceration, conversion to open pyloromyotomy, and wound complications. Perceived advantages of LPM, including excellent visualization, shorter time to full feeds, shorter length of stay, and superior cosmesis compared with the open surgery, have made LPM a mainstay of the pediatric surgical armamentarium.
PREOPERATIVE MANAGEMENT
A good outcome after pyloromyotomy is predicated upon adequate preoperative resuscitation. Children with HPS will usually present with a hypokalemic, hypochloremic metabolic alkalosis. The severity of fluid and electrolyte abnormality is reflected by carbon dioxide12 levels, with increased severity correlating with higher levels in the blood. Five percent dextrose and 0.45 normal saline solution suffices in most cases, delivered at 1.5 to 2 times maintenance rate with an initial bolus of 20 ml/kg of the child’s weight. The fluid is supplemented with potassium if the renal function is normal. Approximately 20% to 36% of infants with pyloric stenosis may present with nonclassic hyperkalemia and 12% to 18% with acidosis instead of alkalosis.13 Fluid resuscitation is again paramount.
DIAGNOSIS AND ERRORS
Preoperative work-up of projectile nonbilious emesis involves a careful history and physical examination, drawing a basic metabolic blood panel with bicarbonate and chloride values and, in most instances, obtaining an ultrasound. The sensitivity and specificity of physical examination alone was found to be 72% and 97%, whereas that of ultrasound was 97% and 100%.14 However, false positives on ultrasound resulting in negative laparotomy were reported at an incidence of 0.7% to 5.3%.15,16
OPERATIVE PROCEDURE
Retraction of the Stomach and Duodenum
Stomach Perforation/Laceration (Laparoscopic and Open)
• Repair
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