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Intraabdominal pyloromyotomy
Intraabdominal
Pyloromyotomy
By William I_. Donnetlan and L. Mason Cobb Lansing, Michigan l lntraabdominal pyloromyotomy was performed consecutive cases, with satisfactory results. Copyright o 1991 by W.B. Saunders Company
in 64
INDEX WORD: Pyloromyotomy.
RESENT INCISIONS for Ramstedt pyloromyotomy are usually made transversely in the right upper quadrant just above the lower edge of the liver. When the pyloric tumor is large, it may be necessary to increase the incision to 4 cm or more before the tumor can be delivered onto the abdominal surface. In fact, the delivery of the “olive” can be time consuming, and may damage the stomach or duodenum.’ To avoid such large incisions and an increased exposure of the small and large bowel, we have developed a technique for incision and spreading of the pylorus within the abdomen during pyloromyotomy.
P
identify the pyloroduodenal junction. At this end a few muscle fibers should be left in place to avoid entering the duodenal mucosa (Fig 3). It is more important to extend the pyloromyotomy at least 1 cm proximally above the thickened pylorus than it is to get the last fibers at the duodenum. This will divide the important Torgersen muscle bands, which may cause obstructing antral spasm.“’ Because the gastric wall is thin in this area, extra care must be taken not to perforate the mucosa during the proximal part of the dissection. Moderately sharp mosquito forceps should be placed beneath all transverse muscle fibers to avoid entering the mucosa. The anesthesiologist is asked again to insufflate 125 to 150 mL of air through the nasogastric tube. Pressure on the stomach across the abdominal wall will identify possible bile-stained leakage through the pyloric mucosa. If none is seen, the stay sutures are removed, and the pylorus is allowed to retract into the abdomen. The wound is closed in standard fashion.
MATERIALS AND METHODS After the induction of anesthesia and intubation, careful abdominal palpation will usually identify the site of the tumor. In the rare event that it cannot be located, it is often found to be under the edge of the liver, To aid its palpation, 75 to 120 mL of air can be insufflated through the nasogastric tube to enlarge the stomach and press the pylorus downward. This will also displace the colon and small bowel away from the incision.* A 2- to 2.5-cm transverse skin incision is made in the right abdomen just above the lower border of the liver (Fig I). The rectus sheath and muscle are split vertically, and the peritoneum and transversalis fascia are incised transversely. If the pyloric tumor is not immediately evident, exploration with the small finger can be used to locate it within the abdomen. The liver edge is drawn upward by means of a small malleable retractor. When the stomach is located, it is followed to the pylorus, which is transfuted with a 4-O Vicryl suture. Three to four such sutures are placed in the thickened muscle without entering the pyloric lumen (Fig 2). Too superficial bites will often cause the sutures to pull out through the friable hypertrophied muscle. When the traction sutures are in place, the pylorus can be drawn upward against the edges of the abdominal incision. It can then be moved from right to left as necessary. The serosal incision and pyloromyotomy are performed in the standard way. At the duodenal end, a blunt forceps is used to
From the Division of Pediatric Surgery, Department of Surgery, Michigan State University, East Lansing, MI. Date accepted: Februury 8,199O. Address reprint requests to William L. Donnellan, MD, PhD, MSV Surgical Services, 1322 E Michigan Ave, Suite 308, Lansing, MI 48912. Copyright o 1991 by W.B. Saunders Company 0022-3468/9112602-0013$03.00/O
174
Fig 1. Transverse incision at liver edge. obliquely from right to left when undisturbed.
The pylorus
passes
Journaloff’ediatric Surgery, Vol26, No 2 (February), 1991: pp 174-175
INTRAABDOMINAL
175
PYLOROMYOTOMY
Fig 2. The pylorus is incised on its serosa and is spread between the traction sutures within the abdomen.
RESULTS
In 64 consecutive cases, there was one small mucosal perforation proximally. This was easily identified and repaired. All other babies were fed at 8 hours, and were routinely discharged the following day if they were retaining feedings well. Postoperative
Fig 3. The duodenum is inverted at the pyloroduodenal junction to assess the adequacy of the pyloromyotomy.
emesis occurred in 22 (34%) of the cases. In most of these, there were only one or two episodes of vomiting. Such babies were discharged within 48 hours of the operation. Emesis continued in three (5%) of the infants for up to 7 days, despite the use of an infant seat and thickened feedings.‘B6 Reoperation was not required in any case.
REFERENCES 1. Scharli A, Sieber WK, Kiesewetter WB: Hypertrophic pyloric stenosis at the Children’s Hospital of Pittsburgh from 1912 to 1967: A critical review of current problems and complications. J Pediatr Surg 4:108-l 14. 1969 2. Schuster SR, Colodny AH: A useful maneuver to simplify pyloromyotomy for hypertrophic pyloric stenosis. Surgery 55:735736,1964 3. Javett SL, Jackson H. Utian HL: Torgersen’s muscle and
infantile hypertrophic pyloric stenosis. J Pediatr Surg 8:383-385, 1973 4. Swischuk LE, Hayden CK, Tyson KR: Atypical muscle hypertrophy in pyloric stenosis. AJR 134:481-484, 1980 5. Spitz L, MacKinnon AE: Posture in the postoperative management of infantile pyloric stenosis. Br J Surg 71:643, 1984 6. Zeidan B, Wyatt J. Mackersie A, et al: Recent results of treatment of infantile hypertrophic pyloric stenosis. Arch Dis Child 63:1060-1064,198s
Pyloromyotomy
By William I_. Donnetlan and L. Mason Cobb Lansing, Michigan l lntraabdominal pyloromyotomy was performed consecutive cases, with satisfactory results. Copyright o 1991 by W.B. Saunders Company
in 64
INDEX WORD: Pyloromyotomy.
RESENT INCISIONS for Ramstedt pyloromyotomy are usually made transversely in the right upper quadrant just above the lower edge of the liver. When the pyloric tumor is large, it may be necessary to increase the incision to 4 cm or more before the tumor can be delivered onto the abdominal surface. In fact, the delivery of the “olive” can be time consuming, and may damage the stomach or duodenum.’ To avoid such large incisions and an increased exposure of the small and large bowel, we have developed a technique for incision and spreading of the pylorus within the abdomen during pyloromyotomy.
P
identify the pyloroduodenal junction. At this end a few muscle fibers should be left in place to avoid entering the duodenal mucosa (Fig 3). It is more important to extend the pyloromyotomy at least 1 cm proximally above the thickened pylorus than it is to get the last fibers at the duodenum. This will divide the important Torgersen muscle bands, which may cause obstructing antral spasm.“’ Because the gastric wall is thin in this area, extra care must be taken not to perforate the mucosa during the proximal part of the dissection. Moderately sharp mosquito forceps should be placed beneath all transverse muscle fibers to avoid entering the mucosa. The anesthesiologist is asked again to insufflate 125 to 150 mL of air through the nasogastric tube. Pressure on the stomach across the abdominal wall will identify possible bile-stained leakage through the pyloric mucosa. If none is seen, the stay sutures are removed, and the pylorus is allowed to retract into the abdomen. The wound is closed in standard fashion.
MATERIALS AND METHODS After the induction of anesthesia and intubation, careful abdominal palpation will usually identify the site of the tumor. In the rare event that it cannot be located, it is often found to be under the edge of the liver, To aid its palpation, 75 to 120 mL of air can be insufflated through the nasogastric tube to enlarge the stomach and press the pylorus downward. This will also displace the colon and small bowel away from the incision.* A 2- to 2.5-cm transverse skin incision is made in the right abdomen just above the lower border of the liver (Fig I). The rectus sheath and muscle are split vertically, and the peritoneum and transversalis fascia are incised transversely. If the pyloric tumor is not immediately evident, exploration with the small finger can be used to locate it within the abdomen. The liver edge is drawn upward by means of a small malleable retractor. When the stomach is located, it is followed to the pylorus, which is transfuted with a 4-O Vicryl suture. Three to four such sutures are placed in the thickened muscle without entering the pyloric lumen (Fig 2). Too superficial bites will often cause the sutures to pull out through the friable hypertrophied muscle. When the traction sutures are in place, the pylorus can be drawn upward against the edges of the abdominal incision. It can then be moved from right to left as necessary. The serosal incision and pyloromyotomy are performed in the standard way. At the duodenal end, a blunt forceps is used to
From the Division of Pediatric Surgery, Department of Surgery, Michigan State University, East Lansing, MI. Date accepted: Februury 8,199O. Address reprint requests to William L. Donnellan, MD, PhD, MSV Surgical Services, 1322 E Michigan Ave, Suite 308, Lansing, MI 48912. Copyright o 1991 by W.B. Saunders Company 0022-3468/9112602-0013$03.00/O
174
Fig 1. Transverse incision at liver edge. obliquely from right to left when undisturbed.
The pylorus
passes
Journaloff’ediatric Surgery, Vol26, No 2 (February), 1991: pp 174-175
INTRAABDOMINAL
175
PYLOROMYOTOMY
Fig 2. The pylorus is incised on its serosa and is spread between the traction sutures within the abdomen.
RESULTS
In 64 consecutive cases, there was one small mucosal perforation proximally. This was easily identified and repaired. All other babies were fed at 8 hours, and were routinely discharged the following day if they were retaining feedings well. Postoperative
Fig 3. The duodenum is inverted at the pyloroduodenal junction to assess the adequacy of the pyloromyotomy.
emesis occurred in 22 (34%) of the cases. In most of these, there were only one or two episodes of vomiting. Such babies were discharged within 48 hours of the operation. Emesis continued in three (5%) of the infants for up to 7 days, despite the use of an infant seat and thickened feedings.‘B6 Reoperation was not required in any case.
REFERENCES 1. Scharli A, Sieber WK, Kiesewetter WB: Hypertrophic pyloric stenosis at the Children’s Hospital of Pittsburgh from 1912 to 1967: A critical review of current problems and complications. J Pediatr Surg 4:108-l 14. 1969 2. Schuster SR, Colodny AH: A useful maneuver to simplify pyloromyotomy for hypertrophic pyloric stenosis. Surgery 55:735736,1964 3. Javett SL, Jackson H. Utian HL: Torgersen’s muscle and
infantile hypertrophic pyloric stenosis. J Pediatr Surg 8:383-385, 1973 4. Swischuk LE, Hayden CK, Tyson KR: Atypical muscle hypertrophy in pyloric stenosis. AJR 134:481-484, 1980 5. Spitz L, MacKinnon AE: Posture in the postoperative management of infantile pyloric stenosis. Br J Surg 71:643, 1984 6. Zeidan B, Wyatt J. Mackersie A, et al: Recent results of treatment of infantile hypertrophic pyloric stenosis. Arch Dis Child 63:1060-1064,198s