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Laparoscopic Pyloromyotomy

Laparoscopic Pyloromyotomy. George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, Missouri. Preoperative Evaluation Pyloric Stenosis. Non-bilious emesis 2-8 wks of age Male:Female 4:1 Dehydration/Metabolic Alkalosis Jaundice 10% Ultrasound - length - > 14 mm

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Laparoscopic Pyloromyotomy

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  1. Laparoscopic Pyloromyotomy George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, Missouri

  2. Preoperative EvaluationPyloric Stenosis • Non-bilious emesis • 2-8 wks of age • Male:Female 4:1 • Dehydration/Metabolic Alkalosis • Jaundice 10% • Ultrasound - length - > 14 mm thickness - > 4 mm

  3. Indications for Surgery • Presence of pyloric stenosis • Need to correct electrolyte abnormalities and dehydration

  4. Patient Positioning • Baby placed across operating table • Table tilted toward surgeon • Monitor in front of surgeon • Assistant/camera holder to right of surgeon • Scrub nurse opposite assistant • Red rubber catheter in stomach

  5. Equipment • 5 mm umbilical cannula – 4 mm, 70o telescope • Arthroscopy knife (Linvatec) • Pyloric spreader • Atraumatic grasping forcep

  6. Tips and Tricks • Set knife at 2 mm depth • Incise serosa and muscle to 2 mm • Sheath knife and use sheath to bluntly separate muscle • Insert pyloric spreader –Gently separate pyloric muscle fibers as you view the submucosa • Measure length – know length of stenosis on ultrasound • Distend stomach with 45-60 cc air • Place omentum over myotomy

  7. Laparoscopic Pyloromyotomy

  8. Alternative Approaches • RUQ or upper midline incision • Circumumbilical incision

  9. Complications • Incomplete myotomy • Mucosal perforation • Wound infection

  10. Post-operative Management • Advance diet per protocol • Tylenol for pain • Feed Like APyloric (FLAP) • NPO for 2 hours • Pedialyte 30cc PO Q 2h X 2, • Formula 30cc ½ str Q 2h X 2, • Formula 30cc full str Q 2h X 2, • Formula 45cc full str Q 3h ad lib

  11. Recent Literature Reports

  12. Retrospective Review – Laparoscopic, Circumumbilical and RUQ Approaches JACS 201:66-70, 2005

  13. Retrospective Review – Laparoscopic, Circumumbilical and RUQ Approaches JACS 201:66-70, 2005

  14. An Effective Pyloromyotomy Length In Infants Undergoing Laparoscopic Pyloromyotomy Daniel J. Ostlie, MD, Charles E. Woodall III, MD, Kerri R. Wade, RN, Charles L. Snyder, MD, George K. Gittes, MD, Ronald J. Sharp, MD, Walter S. Andrews, MD, J. Patrick Murphy, MD, George W. Holcomb III, MD, MBA Children’s Mercy Hospitals and Clinics Kansas City, Missouri Surgery 136:827-32, 2004

  15. Purpose To evaluate whether there is an effective pyloromyotomy length that can prevent the development of an inadequate myotomy

  16. ResultsOctober 1999 – October 2003 • 171 infants • Mean age – 5.2 wks (± 2.8) • Ultrasound • Mean length– 19.52 ± 2.8 mm • Mean thickness– 4.29 ± 0.7 mm Surgery 136:827-32, 2004

  17. Results • Operative time • 23.5 (± 8.3) min • Length of myotomy • 1.94 (± 0.21) cm • Standardized feeding protocol – 33 pts (19%) experienced at least one feeding setback • Hospitalization • Postoperative–32.6 (±27.7) hrs • Total – 53.2 (± 38.7) hrs Surgery 136:827-32, 2004

  18. Results171 Infants • No mucosal perforations • No gastric or duodenal injuries • No inadequate pyloromyotomies Surgery 136:827-32, 2004

  19. Conclusions • Laparoscopic approach for pyloromyotomy is safe and effective • The length of the myotomy can be measured effectively • A pyloromyotomy length of approximately 2 cm is effective in relieving the pyloric obstruction Surgery 136:827-32, 2004

  20. Prospective Randomized Trial of Laparoscopic vs Open Fundoplication

  21. Open Versus Laparoscopic Pyloromyotomy For Pyloric Stenosis: A Prospective Randomized Trial Shawn D. St. Peter George W. Holcomb III Casey M. Calkins Walter S. Andrews J. Patrick Murphy Charles L. Snyder Ronald J. Sharp George K. Gittes Daniel J. Ostlie The Center for Prospective Clinical Trials Children’s Mercy Hospital Kansas City, MO

  22. Introduction We conducted the first large prospective randomized controlled trial investigating the role of laparoscopy in treating pyloric stenosis Ann Surg 244:363-370, 2006

  23. MethodsSample Size • Mean operative times were utilized from retrospective data within our institution • Power = 0.80 and α = 0.05 • 60 patients in each arm • Potentially significant complications occur infrequently • Therefore, a recruitment goal of 100 patients in each arm was established

  24. Assignment • Individual unit randomization sequence • Non-stratified • Blocks of 10 • Allotment obtained from randomization sequence after permission form signed

  25. Interventions • Operations were performed by 7 pediatric surgeons at a single institution • The surgical resident (fellow) or on-call surgeon performed the operation • Allotment had no influence on which surgeon performed the operation

  26. InterventionsOpen Pyloromyotomy • 2-3 cm incision, transverse right upper quadrant or upper midline • Pylorus exteriorized through incision • Incision in pylorus with #15 blade • Muscle spreader used to complete myotomy

  27. InterventionsLaparoscopic Pyloromyotomy • 5 mm port in umbilicus • 2 stab incisions • right and left upper quadrants • 3 mm instruments • Grasper in surgeon’s left hand • Blade followed by spreader in surgeon’s right hand

  28. ManagementDiet Orders • Standard diet order sets for both groups • 2 feedings of Pedialyte® • 2 feedings of ½ strength formula/breast milk • 2 feedings of full strength formula/breast milk • Resume home regimen • Criteria for stopping feeds outlined in order set • Discharged when home diet tolerated

  29. ManagementPain Control • Acetaminophen (10mg/kg) PO/PR every 4 hours as needed for pain • No patients received narcotics

  30. Data Collection • Age • Weight • Electrolytes on presentation • Ultrasound measurements of the pylorus • Operating time • Time to complete advancement of diet • Number of episodes of post-operative emesis • Number of doses of tylenol (10mg/kg) • Length of post-operative hospitalization • Complications

  31. Statistics • Continuous variables were compared using an independent sample, 2-tailed Student’s t- test • Discrete variables were analyzed with Fisher’s exact test • Significance was defined as P value < of 0.05 • All measures evaluated on intention-to-treat basis

  32. ResultsUpon Presentation OPEN(n = 100) LAP (n = 100) P Value (Mean +/- S.E.) (Mean +/- S.E.) 0.77 0.88 0.74 0.72 0.65 Age (weeks) 5.24 +/- 0.25 5.33 +/- 0.22 Thickness (mm) 4.17 +/- 0.08 4.16 +/- 0.09 Length (mm) 19.51 +/- 0.27 19.38 +/- 0.27 Cl -(mmol/L) 99.36 +/- 0.78 99.76 +/- 0.79 HCO3 -(mmol/L) 28.18 +/- 0.51 27.86 +/- 0.49

  33. OR time (mins) 19:28 +/- 0.60 19:34 +/- 0.78 Emesis (#) 2.61 +/- 0.27 1.84 +/- 0.23 Full Feeds (hrs) 21:01 +/- 2.16 19:30 +/- 1.46 LOS(hrs) 33:10 +/- 1.63 29:38 +/- 1.69 Tylenol (doses) 2.23 +/- 0.18 1.59 +/- 0.16 ResultsOutcomes OPEN (n = 100) LAP (n = 100) P Value (Mean +/- S.E.) (Mean +/- S.E.) 0.93 0.05 0.43 0.12 0.01

  34. ResultsComplications • 1 mucosal perforation in the open group • 1 incisional hernia in the open group • 1 laparoscopic case was converted to open • 4 wound infections in the open group compared to 2 wound infections in the laparoscopic group (P = 0.68)

  35. ResultsCosmetic Outcome OPEN LAP

  36. Conclusions • Operative approach for pyloromyotomy has no significant influence on operating time or length of recovery • Laparoscopic pyloromyotomy results in significantly less post-operative discomfort • Fewer episodes of emesis and doses of tylenol • Laparoscopic pyloromyotomy results in obvious cosmetic benefits

  37. Conclusions • All surgeons confirmed they will perform the pyloromyotomy with the laparoscopic approach

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