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Can a simplified algorithm prevent incomplete laparoscopic pyloromyotomy?
Journal of Pediatric Surgery xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Can a simplified algorithm prevent incomplete laparoscopic pyloromyotomy? M. Reza Vahdad a,⁎, Matthias Nissen b, Alexander Semaan a, Tobias Klein a, Emanuel Palade c, Thomas Boemers a, Ralf-Bodo Troebs b, Grigore Cernaianu d a
Department of Pediatric Surgery and Pediatric Urology Kliniken der Stadt Köln GmbH, Kinderkrankenhaus Amsterdamer Strasse 59, 50735 Koeln, Germany Department of Pediatric Surgery, Marienhospital Herne, Ruhr-University of Bochum, Widumerstr. 8, 44627 Herne, Germany Department of Surgery, University Hospital Luebeck, Ratzeburger Allee 160, 23538 Lübeck, Germany d Department of Pediatric Surgery, University Hospital Luebeck, Ratzeburger Allee 160, 23538 Lübeck, Germany b c
a r t i c l e
i n f o
Article history: Received 8 November 2014 Accepted 2 December 2014 Available online xxxx Key words: Incomplete laparoscopic pyloromyotomy Complications Child LESS Trainee
a b s t r a c t Purpose: The purpose of this study is to analyze an algorithm intended to prevent incomplete pyloromyotomy in 3-port laparoscopic (3TP) and laparoendoscopic single-site (LESS-P) procedures in a teaching hospital. Methods: We defined the pyloroduodenal and pyloroantral junctions as anatomical margins prior pyloromyotomy by palpating and coagulating the serosa with the hook cautery instrument. Incomplete pyloromyotomies, mucosa perforations, serosa lacerations, and wound infections were recorded for pediatric surgical trainees (PST) and board-certified pediatric surgeons (BC). Results: We reviewed the medical files of 233 infants, who underwent LESS-P (n = 21), 3TP (n = 71), and open pyloromyotomy (OP, n = 141). No incomplete pyloromyotomies occurred. In contrast to OP, mucosa perforations did not occur in the laparoscopic procedures during the study period (6.38% vs. 0%, P = .013). OP had insignificantly more serosal lacerations (3.5% vs. 1.4%, P = .407). There was no difference in the rate of wound infections between OP and laparoscopic procedures (2.8% vs. 4.3%, P = .715). In the latter, all wound infections were associated with the use of skin adhesive. Conclusions: This algorithm helps avoiding incomplete laparoscopic pyloromyotomy during the learning curve and in a teaching setting. It is not risky to assist 3TP and LESS-P to PST as this led to a decreased rate of mucosa perforations without experiencing incomplete pyloromyotomies. © 2014 Elsevier Inc. All rights reserved.
Laparoscopic pyloromyotomy (LP) is being increasingly performed because of reported benefits like shorter time to achieve full enteral feeding [1,2], requirement of less doses of analgesia [3], and achievement of a higher cosmetic parental satisfaction score [4]. However, with larger procedure numbers becoming available, there are rising concerns about an increased rate of incomplete pyloromyotomy [5]. We present a simple algorithm aiming to avoid incomplete LP both in the conventional 3-trocar (3TP) and in the laparoendoscopic singlesite (LESS-P) procedure. Furthermore, we evaluate this algorithm in the learning period of transition from open pyloromyotomy (OP) to 3TP and, subsequently, to LESS-P. We set a focus on training the procedures to pediatric surgical trainees (PST) and compare the outcome with the procedures
⁎ Corresponding author. Fax: +49 22189075492. E-mail addresses: [email protected] (M.R. Vahdad), [email protected] (M. Nissen), [email protected] (A. Semaan), [email protected] (T. Klein), [email protected] (E. Palade), [email protected] (T. Boemers), [email protected] (R.-B. Troebs), [email protected] (G. Cernaianu).
performed by board certified pediatric surgeons (BC) in the setting of a high-volume teaching center. 1. Methods A standardized intraoperative algorithm to measure a sufficient LP was defined before the first laparoscopic procedure was performed. Incomplete pyloromyotomy was defined as failure to reach ad libitum feeds after initial pyloromyotomy followed by success after redo pyloromyotomy. 1.1. Data collection and inclusion/exclusion criteria After obtaining institutional review board approval (4601–13), a review included all infants with hypertrophic pyloric stenosis who underwent pyloromyotomy between February 2004 and October 2012 in a university department of pediatric surgery. Informed consent was obtained from each patient’s guardian. Data were available for all patients. They were followed up until their discharge from hospital when they had reached full enteral feeding. No patients were excluded from the study. Patients’ medical records were reviewed, and the following data were collected: age at surgery, gender, type of surgical procedure(s), incidence of incomplete
http://dx.doi.org/10.1016/j.jpedsurg.2014.12.004 0022-3468/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Vahdad MR, et al, Can a simplified algorithm prevent incomplete laparoscopic pyloromyotomy?, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.12.004
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M.R. Vahdad et al. / Journal of Pediatric Surgery xxx (2014) xxx–xxx
Fig. 1. Intraoperative images during 3-port laparoscopic pyloromyotomy (3TP). (A) The pyloroduodenal region is identified by palpation with the monopolar hook cautery. The landmark is defined by palpation of the distal part of the pylorus until a loss of resistance is encountered. (B) The position of the pyloroantral junction can be seen where the diameter of the pylorus increases toward the antrum (yellow triangle) and confirmed by a loss of resistance during palpation of the proximal rigid pyloric musculature. (C) Ensemble view of the anatomical landmarks: pyloroduodenal junction (dotted line, 1), pyloroantral junction (dotted line, 2), length of sufficient pyloromyotomy between the anatomical landmarks marked by coagulation of the serosa (stars along white coagulation line, 3). (D) A sufficient pyloromyotomy is obtained if the branches of the laparoscopic pyloric spreader can be spread apart maximally along the middle part of the incision, in such a manner that the mucosa can be clearly seen.
pyloromyotomy, pyloric mucosa perforation, serosal laceration, wound infection, and specialization of the surgeon as being either BC or PST.
1.2. Surgical techniques The standard preoperative therapy included intravenous fluid infusion and correction of the acid–base status. The patients were divided into 3 groups: those who underwent LESS-P through one transumbilical multichannel port, those who underwent standard 3TP, and those who underwent OP. The decision of whether to perform LESS-P, 3TP, or OP was based on the surgeon’s preference. All surgical procedures were performed by BC or by PST under the supervision of BC. We performed OP by a transverse incision in the right upper quadrant. For laparoscopic procedures, we obtained access to the abdominal cavity through an open transumbilical approach. For both LESS-P and 3TP, we used 3 mm × 20 cm straight instruments (Karl-Storz GmbH & Co., Tuttlingen, Germany). For LESS-P, we used a 30° endoscope with a working length of 300 mm, integrated camera, and light source (EndoEye®, Olympus Surgical Technologies Europe, Hamburg, Germany) in order to minimize clashing of instruments. We performed LESS-P using the TriPort® device with 3 gel valves (Olympus Surgical Technologies Europe, Hamburg, Germany) and the Cross-technique, as previously published [6]. For 3TP, we used a separate 5 mm 30° endoscope with a working length of 260 mm (Karl-Storz GmbH & Co.) attached to a camera (Olympus Surgical Technologies, Europe). Further, we placed two 3.5 mm
Fig. 2. Transition from open to laparoscopic pyloromyotomy during the study period. Absolute counts of procedures per year. Open pyloromyotomy (OP), 3-port laparoscopic pyloromyotomy (3TP), laparoendoscopic single-site pyloromyotomy (LESS-P). The three vertical interrupted lines represent the 3 time periods of the study. 1st time period: OP as only available procedure, 2nd time period: introduction of 3TP as alternative to OP, 3rd time period: introduction of LESS-P as alternative to 3TP and OP.
Please cite this article as: Vahdad MR, et al, Can a simplified algorithm prevent incomplete laparoscopic pyloromyotomy?, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.12.004
M.R. Vahdad et al. / Journal of Pediatric Surgery xxx (2014) xxx–xxx
trocars in the left epigastric and right lower quadrant accompanied by a 5.5 mm transumbilical trocar. A grasper and a pylorotome were introduced through the trocars. If the liver was found to obstruct the view on the pyloric region, a percutaneous transabdominal suspension suture around the round ligament of the liver helped retract the liver upward. A standardized algorithm was defined to intraoperatively assess sufficient LP (Video provided as supplement). The pyloroduodenal and pyloroantral junctions were defined as anatomical landmarks and limits of the planned incision. The pyloroduodenal junction was easily palpable with the angled part of the monopolar hook cautery (Fig. 1A). It was encountered where the resistance from the rigid hypertrophic pyloric musculature disappeared. The pyloroantral junction was visible where the diameter of the pylorus increased toward the stomach (yellow triangle in Fig. 1A). Palpation of the pyloroantral junction helped confirm adequate length of the intended pyloromyotomy (Fig. 1B). The distance between the pyloroduodenal and pyloroantral junctions on the serosa was coagulated with a setting of 10 Watts monopolar current. This white coagulation line (Fig. 1C) served as guiding line for the subsequent seromuscular incision, which was performed with the laparoscopic pylorotome. The pyloromyotomy was completed with a laparoscopic pyloric spreader (Fig. 1D). In LESS-P, this instrument could be inserted through the valve of the TriPort®. In 3TP, the left 3 mm trocar had to be removed and the pyloric spreader was inserted directly through the abdominal wall. A sufficient pyloromyotomy was assumed if the branches of the spreader could be spread apart maximally along the entire length of the incision, in such a manner that the mucosa could be clearly seen (Fig. 1D). In LESS-P, the distance between the maximally spread branches of the laparoscopic pyloric spreader was 1.8 cm. After performing the pyloromyotomy, the anesthesiologist was asked to administer 20 ml of physiological saline and 20 ml of air via the nasogastric tube. Subsequently, the patency of the mucosa was checked in order to rule out perforation. After 3TP and LESS-P, the capnoperitoneum was desufflated, endoscopic instruments were removed and the umbilical fascial incision was closed with absorbable sutures. Skin closure was performed by sutures after OP. The skin at the umbilical and the trocar insertion sites after laparoscopic procedures was closed either by applying a skin adhesive (octyl-2-cyanoacrylate, DERMABOND®, ETHICON Johnson & Johnson Medical GmbH, Norderstedt, Germany) or by interrupted absorbable intracutaneous sutures.
1.3. Statistical analysis Comparative statistical analyses were undertaken using Fisher's exact test for categorical data and the Mann–Whitney U test for nonparametric continuous data. Categorical and continuous data are presented as bars and stacked bars, indicating counts, percentages, and means ± standard deviations (SD). Statistical analyses were performed using SPSS® 22 software (IBM®, Munich, Germany). Differences were considered significant at P b .05 (exact significance, 2-sided).
Table 1 Gender and age. Procedure
OP
3TP
LESS-P
N
141
71
21
114:27 37 (42.3 ± 18)
60:11 37 (41.7 ± 18.8)
18:3 38 (37.8 ± 13.7)
Gender Age (days)
m:f ratio Median (mean ± SD)
Distribution of male:female ratio (m:f) and age at diagnosis in days. Open pyloromyotomy (OP), 3-port laparoscopic pyloromyotomy (3TP), laparoendoscopic single-site pyloromyotomy (LESS-P). N = number of patients.
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2. Results 2.1. Patient characteristics Pyloromyotomies were performed in 233 infants (192 boys and 41 girls) with a mean age at diagnosis of 42.1 ± 17.9 days and a range of 125 days (Table 1). From 2008 on, we performed the transition from OP to 3TP (Fig. 2). In 2011, LESS-P was introduced as an additional way to perform LP. Depending on the available procedures, we distinguished 3 time periods (Fig. 2). Open pyloromyotomy was the main procedure during the 55 months lasting 1st time period. It included the beginning of the study in February 2004 and ended before the first 3TP was performed in October 2008. 3TP and OP were the main procedures during the 34 months lasting 2nd time period, which included the first 3TP and ended before the first LESS-P was performed in August 2011. During the 14 months lasting 3rd time period, all except one procedure were 3TP and LESSP. This time period started with the first LESS-P and lasted until the end of the study in October 2012. No additional trocars had to be inserted for laparoscopic pyloromyotomies. Conversions to OP were performed in 2 patients. One patient was intraoperatively converted from 3TP in order to rule out thermal injury of the pyloric mucosa after coagulating the pyloric musculature with an accidentally higher setting of 40 Watt monopolar current. After conversion, we ruled out thermal injury of the mucosa and completed the procedure. The patient recovered uneventfully. In another patient, persistent vomiting after LESS-P was encountered. The investigation of the gastrointestinal passage with a water-soluble contrast agent and subsequent x-ray imaging showed a persistent stop in the proximal duodenal region. At redo laparoscopy, no evidence of incomplete pyloromyotomy was found. In this case, we performed laparotomy and could easily pass through the pylorus with a balloon-catheter inserted via gastrotomy. We inflated the balloon in the duodenum and retracted it into the stomach. This maneuver did not extend the length of the previous pyloromytomy. It might be possible that this action ruptured a duodenal membrane and established the duodenal passage, as the child reached full enteral feeds postoperatively. 2.2. Outcomes We encountered no incomplete pyloromyotomies when the primary operation was performed in our department. One patient presented with incomplete pyloromyotomy after OP in another hospital. We achieved complete pyloromyotomy by 3TP. In contrast to OP, we encountered no mucosa perforations (Table 2) during the study period in the laparoscopic procedures (9 vs. 0, P = .013). 5 serosal lacerations occurred in OP (Table 2), none in 3TP, and 1 in the LESS-P group. Despite the fact that we encountered more serosal lacerations in OP, we could not find a significant difference when comparing it with 3TP and LESS-P (P = .407). After closing the skin with sutures after OP, 4 wound infections occurred (Table 2). 2 patients after 3TP and 2 patients after LESS-P developed wound infections at the umbilicus, caused by rests of skin adhesives. 3 wound infections after OP and 4 wound infections after 3TP and LESS-P required surgical revision. There was no difference in the rate of total wound infections between OP and laparoscopic procedures (4 vs. 4, P = .715). After returning to skin closure to be performed by intracuticular sutures, no further wound infections were encountered in after LP. 2.3. Impact on education of PST 7 BC and 17 PST performed OP, while 4 BC and 8 PST performed the laparoscopic procedures. The same surgeons operated on patients from different treatment groups. The institutional learning curve for 3TP consisted in the first 40 procedures that were performed by 4 BC. For
Please cite this article as: Vahdad MR, et al, Can a simplified algorithm prevent incomplete laparoscopic pyloromyotomy?, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.12.004
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M.R. Vahdad et al. / Journal of Pediatric Surgery xxx (2014) xxx–xxx
Table 2 Complications. Surgical procedure
OP
Specialization
PST
BC
3TP PST
BC
LESS-P PST
BC
N (%) Incomplete pyloromyotomy (%) Mucosa perforations (%) Serosal lacerations (%) Wound infections (%)
81 (57.4) 0 (0) 6 (7.4) 3 (3.7) 2 (2.5)
60 (42.6) 0 (0) 3 (5.0) 2 (3.3) 2 (3.3)
11 (15.5) 0 (0) 0 (0) 0 (0) 0 (0)
60 (84.5) 0 (0) 0 (0) 1 (1.7) 2 (3.3)
8 (38.1) 0 (0) 0 (0) 0 (0) 1 (12.5)
13 (61.9) 0 (0) 0 (0) 0 (0) 1 (7.7)
Distribution of mucosa perforations, serosal lacerations, wound infections. Open pyloromyotomy (OP), 3-port laparoscopic pyloromyotomy (3TP), laparoendoscopic single-site pyloromyotomy (LESS-P).
LESS-P, the institutional learning curve consisted in the first 12 LESS-P that were performed by 3 BC. Accordingly, after an average of 10 3TP and an average of 4 LESS-P, BC started assisting procedures to PST. During this learning curve of the BC there was one serosal laceration in a LESS-P, that required no further procedures. No serosal lacerations occurred when PST performed 3TP and LESS-P. The percentage of procedures performed by PST declined (Fig. 3) from the era of OP to the era when 3TP was introduced (62.7% vs. 12.8%, P = .000). However, after introduction of LESS-P, the percentage of procedures performed by PST moved closer to the value of the OP era (43.2% vs. 62.7%, P = .055). Moreover, during the last period, when LESS-P and 3TP became the most frequently used procedures, there was no significant difference in the percentage of 3TP and LESS-P (Table 4 and Fig. 4) performed by PST (53.3% vs. 38.1%, P = .500).
3. Discussion Incomplete pyloromyotomy was suspected to occur more often after LP than OP [7,8]. In an attempt to avoid this complication, in 2004, Ostlie et al. [9] and in 2006, St Peter et al. [3] published a detailed algorithm and data of more than 270 laparoscopic pyloromyotomies, demonstrating that a pyloromyotomy with a minimum length of 2 cm
Fig. 3. Influence of the different time periods of the study on the counts of pyloromyotomies done by pediatric surgical trainees (PST) and board-certified pediatric surgeons (BC). Open pyloromyotomy (OP), 3-port laparoscopic pyloromyotomy (3TP), laparoendoscopic single-site pyloromyotomy (LESS-P). Time period 1 (OP as only available procedure, February 2004–October 2008), time period 2 (introduction of 3TP as alternative to OP, October 2008–August 2011), time period 3 (introduction of LESS-P as alternative to 3TP and OP, August 2011–October 2012). The stacked bars represent the absolute counts of procedures. *** indicates P b .001.
(measured intraoperatively with an intracorporally placed length of string) was able to prevent incomplete pyloromyotomy. However, despite the algorithm being published, this did not prevent the higher incidence of incomplete pyloromyotomy with laparoscopy encountered in a prospective multicenter study including 1802 LP, which started in 2007 and was published in 2014 [5]. Based on the published algorithm [3,9], our goal was to develop a simplified way for defining and precisely marking the anatomical margins for a sufficient pyloromyotomy. The main advantage of our algorithm was that it created a standardized guiding line between reproducible anatomic landmarks. This guiding line could be used directly during the incision for pyloromyotomy. We found that visualization of the mucosa on the entire length of the pyloromyotomy was important to avoid incomplete pyloromyotomy. This was easily accomplished, once the branches of the pyloric spreader could be spread maximally apart, perpendicular to the longitudinal axis of the pylorus. In our study, this algorithm successfully prevented incomplete LP. It proved to be a valuable tool in the hands of BC as they performed the transition from OP to two different LP techniques. In addition, it could be easily taught to PST, and again proved to be a valuable tool in their hands, as no single incomplete pyloromyotomy occurred. One easily preventable complication of the method consists in coagulation with a too high energy setting, as this can render the pyloric musculature more rigid and subsequent laparoscopic spreading more difficult. We had to convert one procedure to OP when an accidental higher setting of 40 Watts was left unchanged from the previous operation. We successfully used 10 Watts without any complication in 92 patients.
Fig. 4. Distribution of the different type of surgical procedures among pediatric surgical trainees (PST) and board-certified pediatric surgeons (BC). Open pyloromyotomy (OP), 3-port laparoscopic pyloromyotomy (3TP), laparoendoscopic single-site pyloromyotomy (LESS-P). The stacked bars represent the absolute counts of procedures for BC and PST. *** indicates P b .001,* indicates P b .05.
Please cite this article as: Vahdad MR, et al, Can a simplified algorithm prevent incomplete laparoscopic pyloromyotomy?, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.12.004
M.R. Vahdad et al. / Journal of Pediatric Surgery xxx (2014) xxx–xxx
OP was not superior to 3TP and LESS-P concerning mucosa perforations. This finding is in accordance with the recently published multicenter study [5] and previous reports [7,10,11]. There was no statistical difference in serosal lacerations between OP and LP. The only serosa laceration in laparoscopic procedures was encountered during the learning curve of BC when performing LESS-P and learning the Cross-technique. The laceration required no additional procedures and the patient recovered uneventfully. Moreover, when PST performed laparoscopic pyloromyotomies, no serosal lacerations occurred. This confers LP a technical advantage over OP, as stated already previously by other authors [2,3]. In the OPs that were evaluated for our study, 3 (3.7%) serosal lacerations were recorded for PST, but also 2 (3.3%) serosal lacerations for BC. LP apparently showed the same rate of wound infections as OP but all wound infections in LP were associated with the use of skin adhesives, whereas wound infections in OP occurred independently of skin adhesives. We initially chose to close the skin in LP using skin adhesives, as LP is considered a clean procedure and data from pediatric inguinal herniorrhaphies reported a faster time for skin closure without an increased rate of wound infections [12]. One possible explanation for the wound infections encountered while using skin adhesives might be that after recent umbilical cord separation in newborns, debris and bacteria are located in the moist and dirty folds of the umbilicus [13], and that sealing this area with the skin adhesive might contribute to accumulation of bacteria on the fresh wound. In consequence, we recommend not to use skin adhesives for the closure of the umbilical wound after LP. While a systematic review and meta-analysis of LP vs. OP associated a lower rate of wound complications with LP [14], other studies did not find a significant difference [2,7]. In fact, when not using skin adhesives, we did not encounter a single wound infection in LP. The observation that PST operate less laparoscopic pyloromyotomies than OP as stated by Hall et al. 2009 [2] holds true in our study during the initial transition period from OP to LP. We chose to let BC operate during this transition period as data from the literature [7,15] suggested this period to be vulnerable to more complications. Accordingly, in our setting, we chose BC to perform an average of 10 3TP before assigning the procedure to PST. When PST were trained by those BC to perform 3TP, no intraoperative complications occurred. However, during time, when observing PST performing 3TP, we felt that they intuitively coped very well with the new method and that PST could be allowed earlier to participate in LP. Accordingly, we chose to distribute LESS-P to PST after only an average of 4 procedures had been trained by the assisting BC, obtaining equally good results. As stated by other authors [16,17], we found LESS-P to be a practicable procedure with a similar outcome as 3TP. In fact, during the last time period of the study, PST performed almost the same percentage of LP than BC, confirming the published data by Hall et al. in 2014 [5], that in most teaching centers, PST perform
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nowadays an equal amount of LP as BC. In our study, LP seems to be the safer procedure than OP in the hands of PST with regard to mucosa perforations and serosal lacerations and is in accordance with the above mentioned recent study by Hall et al. 2014 [5], which states that the grade of the primary operator does not lead to a higher rate of complications in LP. 4. Conclusions The presented algorithm effectively prevented incomplete LP. The algorithm was successful both when BC learned it during the transition period from OP to LP, and during the subsequent training of PST. The algorithm proved to be simple to be performed in two different LP techniques. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.jpedsurg.2014.12.004. References [1] Carrington EV, Hall NJ, Pacilli M, et al. Cost-effectiveness of laparoscopic versus open pyloromyotomy. J Surg Res 2012;178:315–20. [2] Hall NJ, Pacilli M, Eaton S, et al. Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: a double-blind multicentre randomised controlled trial. Lancet 2009;373:390–8. [3] St Peter SD, Holcomb III GW, Calkins CM, et al. Open versus laparoscopic pyloromyotomy for pyloric stenosis: a prospective, randomized trial. Ann Surg 2006;244:363–70. [4] Siddiqui S, Heidel RE, Angel CA, et al. Pyloromyotomy: randomized control trial of laparoscopic vs open technique. J Pediatr Surg 2012;47:93–8. [5] Hall NJ, Eaton S, Seims A, et al. Risk of incomplete pyloromyotomy and mucosal perforation in open and laparoscopic pyloromyotomy. J Pediatr Surg 2014;49:1083–6. [6] Muensterer OJ, Chong AJ, Georgeson KE, et al. The Cross-technique for singleincision pediatric endosurgical pyloromyotomy. Surg Endosc 2011;25:3414–8. [7] Adibe OO, Nichol PF, Flake AW, et al. Comparison of outcomes after laparoscopic and open pyloromyotomy at a high-volume pediatric teaching hospital. J Pediatr Surg 2006;41:1676–8. [8] Yagmurlu A, Barnhart DC, Vernon A, et al. Comparison of the incidence of complications in open and laparoscopic pyloromyotomy: a concurrent single institution series. J Pediatr Surg 2004;39:292–6. [9] Ostlie DJ, Woodall CE, Wade KR, et al. An effective pyloromyotomy length in infants undergoing laparoscopic pyloromyotomy. Surgery 2004;136:827–32. [10] Campbell BT, McLean K, Barnhart DC, et al. A comparison of laparoscopic and open pyloromyotomy at a teaching hospital. J Pediatr Surg 2002;37:1068–71. [11] Oomen M, Bakx R, Peeters B, et al. Laparoscopic pyloromyotomy, the tail of the learning curve. Surg Endosc 2013;27:3705–9. [12] Brown JK, Campbell BT, Drongowski RA, et al. A prospective, randomized comparison of skin adhesive and subcuticular suture for closure of pediatric hernia incisions: cost and cosmetic considerations. J Pediatr Surg 2009;44:1418–22. [13] Katz MS, Schwartz MZ, Moront ML, et al. Prophylactic antibiotics do not decrease the incidence of wound infections after laparoscopic pyloromyotomy. J Pediatr Surg 2011;46:1086–8. [14] Sola JE, Neville HL. Laparoscopic vs open pyloromyotomy: a systematic review and meta-analysis. J Pediatr Surg 2009;44:1631–7. [15] Oomen MW, Hoekstra LT, Bakx R, et al. Learning curves for pediatric laparoscopy: how many operations are enough? The Amsterdam experience with laparoscopic pyloromyotomy. Surg Endosc 2010;24:1829–33. [16] Kozlov Y, Novogilov V, Podkamenev A, et al. Single-incision laparoscopic surgery for pyloric stenosis. Pediatr Surg Int 2012;28:347–50. [17] Li B, Chen WB, Wang SQ, et al. Single-site umbilical laparoscopic pyloromyotomy in neonates less than 21-day old. Surg Today 2015;45:29–33. http://dx.doi.org/10. 1007/s00595-014-0854-z.
Please cite this article as: Vahdad MR, et al, Can a simplified algorithm prevent incomplete laparoscopic pyloromyotomy?, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.12.004
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Can a simplified algorithm prevent incomplete laparoscopic pyloromyotomy? M. Reza Vahdad a,⁎, Matthias Nissen b, Alexander Semaan a, Tobias Klein a, Emanuel Palade c, Thomas Boemers a, Ralf-Bodo Troebs b, Grigore Cernaianu d a
Department of Pediatric Surgery and Pediatric Urology Kliniken der Stadt Köln GmbH, Kinderkrankenhaus Amsterdamer Strasse 59, 50735 Koeln, Germany Department of Pediatric Surgery, Marienhospital Herne, Ruhr-University of Bochum, Widumerstr. 8, 44627 Herne, Germany Department of Surgery, University Hospital Luebeck, Ratzeburger Allee 160, 23538 Lübeck, Germany d Department of Pediatric Surgery, University Hospital Luebeck, Ratzeburger Allee 160, 23538 Lübeck, Germany b c
a r t i c l e
i n f o
Article history: Received 8 November 2014 Accepted 2 December 2014 Available online xxxx Key words: Incomplete laparoscopic pyloromyotomy Complications Child LESS Trainee
a b s t r a c t Purpose: The purpose of this study is to analyze an algorithm intended to prevent incomplete pyloromyotomy in 3-port laparoscopic (3TP) and laparoendoscopic single-site (LESS-P) procedures in a teaching hospital. Methods: We defined the pyloroduodenal and pyloroantral junctions as anatomical margins prior pyloromyotomy by palpating and coagulating the serosa with the hook cautery instrument. Incomplete pyloromyotomies, mucosa perforations, serosa lacerations, and wound infections were recorded for pediatric surgical trainees (PST) and board-certified pediatric surgeons (BC). Results: We reviewed the medical files of 233 infants, who underwent LESS-P (n = 21), 3TP (n = 71), and open pyloromyotomy (OP, n = 141). No incomplete pyloromyotomies occurred. In contrast to OP, mucosa perforations did not occur in the laparoscopic procedures during the study period (6.38% vs. 0%, P = .013). OP had insignificantly more serosal lacerations (3.5% vs. 1.4%, P = .407). There was no difference in the rate of wound infections between OP and laparoscopic procedures (2.8% vs. 4.3%, P = .715). In the latter, all wound infections were associated with the use of skin adhesive. Conclusions: This algorithm helps avoiding incomplete laparoscopic pyloromyotomy during the learning curve and in a teaching setting. It is not risky to assist 3TP and LESS-P to PST as this led to a decreased rate of mucosa perforations without experiencing incomplete pyloromyotomies. © 2014 Elsevier Inc. All rights reserved.
Laparoscopic pyloromyotomy (LP) is being increasingly performed because of reported benefits like shorter time to achieve full enteral feeding [1,2], requirement of less doses of analgesia [3], and achievement of a higher cosmetic parental satisfaction score [4]. However, with larger procedure numbers becoming available, there are rising concerns about an increased rate of incomplete pyloromyotomy [5]. We present a simple algorithm aiming to avoid incomplete LP both in the conventional 3-trocar (3TP) and in the laparoendoscopic singlesite (LESS-P) procedure. Furthermore, we evaluate this algorithm in the learning period of transition from open pyloromyotomy (OP) to 3TP and, subsequently, to LESS-P. We set a focus on training the procedures to pediatric surgical trainees (PST) and compare the outcome with the procedures
⁎ Corresponding author. Fax: +49 22189075492. E-mail addresses: [email protected] (M.R. Vahdad), [email protected] (M. Nissen), [email protected] (A. Semaan), [email protected] (T. Klein), [email protected] (E. Palade), [email protected] (T. Boemers), [email protected] (R.-B. Troebs), [email protected] (G. Cernaianu).
performed by board certified pediatric surgeons (BC) in the setting of a high-volume teaching center. 1. Methods A standardized intraoperative algorithm to measure a sufficient LP was defined before the first laparoscopic procedure was performed. Incomplete pyloromyotomy was defined as failure to reach ad libitum feeds after initial pyloromyotomy followed by success after redo pyloromyotomy. 1.1. Data collection and inclusion/exclusion criteria After obtaining institutional review board approval (4601–13), a review included all infants with hypertrophic pyloric stenosis who underwent pyloromyotomy between February 2004 and October 2012 in a university department of pediatric surgery. Informed consent was obtained from each patient’s guardian. Data were available for all patients. They were followed up until their discharge from hospital when they had reached full enteral feeding. No patients were excluded from the study. Patients’ medical records were reviewed, and the following data were collected: age at surgery, gender, type of surgical procedure(s), incidence of incomplete
http://dx.doi.org/10.1016/j.jpedsurg.2014.12.004 0022-3468/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Vahdad MR, et al, Can a simplified algorithm prevent incomplete laparoscopic pyloromyotomy?, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.12.004
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M.R. Vahdad et al. / Journal of Pediatric Surgery xxx (2014) xxx–xxx
Fig. 1. Intraoperative images during 3-port laparoscopic pyloromyotomy (3TP). (A) The pyloroduodenal region is identified by palpation with the monopolar hook cautery. The landmark is defined by palpation of the distal part of the pylorus until a loss of resistance is encountered. (B) The position of the pyloroantral junction can be seen where the diameter of the pylorus increases toward the antrum (yellow triangle) and confirmed by a loss of resistance during palpation of the proximal rigid pyloric musculature. (C) Ensemble view of the anatomical landmarks: pyloroduodenal junction (dotted line, 1), pyloroantral junction (dotted line, 2), length of sufficient pyloromyotomy between the anatomical landmarks marked by coagulation of the serosa (stars along white coagulation line, 3). (D) A sufficient pyloromyotomy is obtained if the branches of the laparoscopic pyloric spreader can be spread apart maximally along the middle part of the incision, in such a manner that the mucosa can be clearly seen.
pyloromyotomy, pyloric mucosa perforation, serosal laceration, wound infection, and specialization of the surgeon as being either BC or PST.
1.2. Surgical techniques The standard preoperative therapy included intravenous fluid infusion and correction of the acid–base status. The patients were divided into 3 groups: those who underwent LESS-P through one transumbilical multichannel port, those who underwent standard 3TP, and those who underwent OP. The decision of whether to perform LESS-P, 3TP, or OP was based on the surgeon’s preference. All surgical procedures were performed by BC or by PST under the supervision of BC. We performed OP by a transverse incision in the right upper quadrant. For laparoscopic procedures, we obtained access to the abdominal cavity through an open transumbilical approach. For both LESS-P and 3TP, we used 3 mm × 20 cm straight instruments (Karl-Storz GmbH & Co., Tuttlingen, Germany). For LESS-P, we used a 30° endoscope with a working length of 300 mm, integrated camera, and light source (EndoEye®, Olympus Surgical Technologies Europe, Hamburg, Germany) in order to minimize clashing of instruments. We performed LESS-P using the TriPort® device with 3 gel valves (Olympus Surgical Technologies Europe, Hamburg, Germany) and the Cross-technique, as previously published [6]. For 3TP, we used a separate 5 mm 30° endoscope with a working length of 260 mm (Karl-Storz GmbH & Co.) attached to a camera (Olympus Surgical Technologies, Europe). Further, we placed two 3.5 mm
Fig. 2. Transition from open to laparoscopic pyloromyotomy during the study period. Absolute counts of procedures per year. Open pyloromyotomy (OP), 3-port laparoscopic pyloromyotomy (3TP), laparoendoscopic single-site pyloromyotomy (LESS-P). The three vertical interrupted lines represent the 3 time periods of the study. 1st time period: OP as only available procedure, 2nd time period: introduction of 3TP as alternative to OP, 3rd time period: introduction of LESS-P as alternative to 3TP and OP.
Please cite this article as: Vahdad MR, et al, Can a simplified algorithm prevent incomplete laparoscopic pyloromyotomy?, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.12.004
M.R. Vahdad et al. / Journal of Pediatric Surgery xxx (2014) xxx–xxx
trocars in the left epigastric and right lower quadrant accompanied by a 5.5 mm transumbilical trocar. A grasper and a pylorotome were introduced through the trocars. If the liver was found to obstruct the view on the pyloric region, a percutaneous transabdominal suspension suture around the round ligament of the liver helped retract the liver upward. A standardized algorithm was defined to intraoperatively assess sufficient LP (Video provided as supplement). The pyloroduodenal and pyloroantral junctions were defined as anatomical landmarks and limits of the planned incision. The pyloroduodenal junction was easily palpable with the angled part of the monopolar hook cautery (Fig. 1A). It was encountered where the resistance from the rigid hypertrophic pyloric musculature disappeared. The pyloroantral junction was visible where the diameter of the pylorus increased toward the stomach (yellow triangle in Fig. 1A). Palpation of the pyloroantral junction helped confirm adequate length of the intended pyloromyotomy (Fig. 1B). The distance between the pyloroduodenal and pyloroantral junctions on the serosa was coagulated with a setting of 10 Watts monopolar current. This white coagulation line (Fig. 1C) served as guiding line for the subsequent seromuscular incision, which was performed with the laparoscopic pylorotome. The pyloromyotomy was completed with a laparoscopic pyloric spreader (Fig. 1D). In LESS-P, this instrument could be inserted through the valve of the TriPort®. In 3TP, the left 3 mm trocar had to be removed and the pyloric spreader was inserted directly through the abdominal wall. A sufficient pyloromyotomy was assumed if the branches of the spreader could be spread apart maximally along the entire length of the incision, in such a manner that the mucosa could be clearly seen (Fig. 1D). In LESS-P, the distance between the maximally spread branches of the laparoscopic pyloric spreader was 1.8 cm. After performing the pyloromyotomy, the anesthesiologist was asked to administer 20 ml of physiological saline and 20 ml of air via the nasogastric tube. Subsequently, the patency of the mucosa was checked in order to rule out perforation. After 3TP and LESS-P, the capnoperitoneum was desufflated, endoscopic instruments were removed and the umbilical fascial incision was closed with absorbable sutures. Skin closure was performed by sutures after OP. The skin at the umbilical and the trocar insertion sites after laparoscopic procedures was closed either by applying a skin adhesive (octyl-2-cyanoacrylate, DERMABOND®, ETHICON Johnson & Johnson Medical GmbH, Norderstedt, Germany) or by interrupted absorbable intracutaneous sutures.
1.3. Statistical analysis Comparative statistical analyses were undertaken using Fisher's exact test for categorical data and the Mann–Whitney U test for nonparametric continuous data. Categorical and continuous data are presented as bars and stacked bars, indicating counts, percentages, and means ± standard deviations (SD). Statistical analyses were performed using SPSS® 22 software (IBM®, Munich, Germany). Differences were considered significant at P b .05 (exact significance, 2-sided).
Table 1 Gender and age. Procedure
OP
3TP
LESS-P
N
141
71
21
114:27 37 (42.3 ± 18)
60:11 37 (41.7 ± 18.8)
18:3 38 (37.8 ± 13.7)
Gender Age (days)
m:f ratio Median (mean ± SD)
Distribution of male:female ratio (m:f) and age at diagnosis in days. Open pyloromyotomy (OP), 3-port laparoscopic pyloromyotomy (3TP), laparoendoscopic single-site pyloromyotomy (LESS-P). N = number of patients.
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2. Results 2.1. Patient characteristics Pyloromyotomies were performed in 233 infants (192 boys and 41 girls) with a mean age at diagnosis of 42.1 ± 17.9 days and a range of 125 days (Table 1). From 2008 on, we performed the transition from OP to 3TP (Fig. 2). In 2011, LESS-P was introduced as an additional way to perform LP. Depending on the available procedures, we distinguished 3 time periods (Fig. 2). Open pyloromyotomy was the main procedure during the 55 months lasting 1st time period. It included the beginning of the study in February 2004 and ended before the first 3TP was performed in October 2008. 3TP and OP were the main procedures during the 34 months lasting 2nd time period, which included the first 3TP and ended before the first LESS-P was performed in August 2011. During the 14 months lasting 3rd time period, all except one procedure were 3TP and LESSP. This time period started with the first LESS-P and lasted until the end of the study in October 2012. No additional trocars had to be inserted for laparoscopic pyloromyotomies. Conversions to OP were performed in 2 patients. One patient was intraoperatively converted from 3TP in order to rule out thermal injury of the pyloric mucosa after coagulating the pyloric musculature with an accidentally higher setting of 40 Watt monopolar current. After conversion, we ruled out thermal injury of the mucosa and completed the procedure. The patient recovered uneventfully. In another patient, persistent vomiting after LESS-P was encountered. The investigation of the gastrointestinal passage with a water-soluble contrast agent and subsequent x-ray imaging showed a persistent stop in the proximal duodenal region. At redo laparoscopy, no evidence of incomplete pyloromyotomy was found. In this case, we performed laparotomy and could easily pass through the pylorus with a balloon-catheter inserted via gastrotomy. We inflated the balloon in the duodenum and retracted it into the stomach. This maneuver did not extend the length of the previous pyloromytomy. It might be possible that this action ruptured a duodenal membrane and established the duodenal passage, as the child reached full enteral feeds postoperatively. 2.2. Outcomes We encountered no incomplete pyloromyotomies when the primary operation was performed in our department. One patient presented with incomplete pyloromyotomy after OP in another hospital. We achieved complete pyloromyotomy by 3TP. In contrast to OP, we encountered no mucosa perforations (Table 2) during the study period in the laparoscopic procedures (9 vs. 0, P = .013). 5 serosal lacerations occurred in OP (Table 2), none in 3TP, and 1 in the LESS-P group. Despite the fact that we encountered more serosal lacerations in OP, we could not find a significant difference when comparing it with 3TP and LESS-P (P = .407). After closing the skin with sutures after OP, 4 wound infections occurred (Table 2). 2 patients after 3TP and 2 patients after LESS-P developed wound infections at the umbilicus, caused by rests of skin adhesives. 3 wound infections after OP and 4 wound infections after 3TP and LESS-P required surgical revision. There was no difference in the rate of total wound infections between OP and laparoscopic procedures (4 vs. 4, P = .715). After returning to skin closure to be performed by intracuticular sutures, no further wound infections were encountered in after LP. 2.3. Impact on education of PST 7 BC and 17 PST performed OP, while 4 BC and 8 PST performed the laparoscopic procedures. The same surgeons operated on patients from different treatment groups. The institutional learning curve for 3TP consisted in the first 40 procedures that were performed by 4 BC. For
Please cite this article as: Vahdad MR, et al, Can a simplified algorithm prevent incomplete laparoscopic pyloromyotomy?, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.12.004
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Table 2 Complications. Surgical procedure
OP
Specialization
PST
BC
3TP PST
BC
LESS-P PST
BC
N (%) Incomplete pyloromyotomy (%) Mucosa perforations (%) Serosal lacerations (%) Wound infections (%)
81 (57.4) 0 (0) 6 (7.4) 3 (3.7) 2 (2.5)
60 (42.6) 0 (0) 3 (5.0) 2 (3.3) 2 (3.3)
11 (15.5) 0 (0) 0 (0) 0 (0) 0 (0)
60 (84.5) 0 (0) 0 (0) 1 (1.7) 2 (3.3)
8 (38.1) 0 (0) 0 (0) 0 (0) 1 (12.5)
13 (61.9) 0 (0) 0 (0) 0 (0) 1 (7.7)
Distribution of mucosa perforations, serosal lacerations, wound infections. Open pyloromyotomy (OP), 3-port laparoscopic pyloromyotomy (3TP), laparoendoscopic single-site pyloromyotomy (LESS-P).
LESS-P, the institutional learning curve consisted in the first 12 LESS-P that were performed by 3 BC. Accordingly, after an average of 10 3TP and an average of 4 LESS-P, BC started assisting procedures to PST. During this learning curve of the BC there was one serosal laceration in a LESS-P, that required no further procedures. No serosal lacerations occurred when PST performed 3TP and LESS-P. The percentage of procedures performed by PST declined (Fig. 3) from the era of OP to the era when 3TP was introduced (62.7% vs. 12.8%, P = .000). However, after introduction of LESS-P, the percentage of procedures performed by PST moved closer to the value of the OP era (43.2% vs. 62.7%, P = .055). Moreover, during the last period, when LESS-P and 3TP became the most frequently used procedures, there was no significant difference in the percentage of 3TP and LESS-P (Table 4 and Fig. 4) performed by PST (53.3% vs. 38.1%, P = .500).
3. Discussion Incomplete pyloromyotomy was suspected to occur more often after LP than OP [7,8]. In an attempt to avoid this complication, in 2004, Ostlie et al. [9] and in 2006, St Peter et al. [3] published a detailed algorithm and data of more than 270 laparoscopic pyloromyotomies, demonstrating that a pyloromyotomy with a minimum length of 2 cm
Fig. 3. Influence of the different time periods of the study on the counts of pyloromyotomies done by pediatric surgical trainees (PST) and board-certified pediatric surgeons (BC). Open pyloromyotomy (OP), 3-port laparoscopic pyloromyotomy (3TP), laparoendoscopic single-site pyloromyotomy (LESS-P). Time period 1 (OP as only available procedure, February 2004–October 2008), time period 2 (introduction of 3TP as alternative to OP, October 2008–August 2011), time period 3 (introduction of LESS-P as alternative to 3TP and OP, August 2011–October 2012). The stacked bars represent the absolute counts of procedures. *** indicates P b .001.
(measured intraoperatively with an intracorporally placed length of string) was able to prevent incomplete pyloromyotomy. However, despite the algorithm being published, this did not prevent the higher incidence of incomplete pyloromyotomy with laparoscopy encountered in a prospective multicenter study including 1802 LP, which started in 2007 and was published in 2014 [5]. Based on the published algorithm [3,9], our goal was to develop a simplified way for defining and precisely marking the anatomical margins for a sufficient pyloromyotomy. The main advantage of our algorithm was that it created a standardized guiding line between reproducible anatomic landmarks. This guiding line could be used directly during the incision for pyloromyotomy. We found that visualization of the mucosa on the entire length of the pyloromyotomy was important to avoid incomplete pyloromyotomy. This was easily accomplished, once the branches of the pyloric spreader could be spread maximally apart, perpendicular to the longitudinal axis of the pylorus. In our study, this algorithm successfully prevented incomplete LP. It proved to be a valuable tool in the hands of BC as they performed the transition from OP to two different LP techniques. In addition, it could be easily taught to PST, and again proved to be a valuable tool in their hands, as no single incomplete pyloromyotomy occurred. One easily preventable complication of the method consists in coagulation with a too high energy setting, as this can render the pyloric musculature more rigid and subsequent laparoscopic spreading more difficult. We had to convert one procedure to OP when an accidental higher setting of 40 Watts was left unchanged from the previous operation. We successfully used 10 Watts without any complication in 92 patients.
Fig. 4. Distribution of the different type of surgical procedures among pediatric surgical trainees (PST) and board-certified pediatric surgeons (BC). Open pyloromyotomy (OP), 3-port laparoscopic pyloromyotomy (3TP), laparoendoscopic single-site pyloromyotomy (LESS-P). The stacked bars represent the absolute counts of procedures for BC and PST. *** indicates P b .001,* indicates P b .05.
Please cite this article as: Vahdad MR, et al, Can a simplified algorithm prevent incomplete laparoscopic pyloromyotomy?, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.12.004
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OP was not superior to 3TP and LESS-P concerning mucosa perforations. This finding is in accordance with the recently published multicenter study [5] and previous reports [7,10,11]. There was no statistical difference in serosal lacerations between OP and LP. The only serosa laceration in laparoscopic procedures was encountered during the learning curve of BC when performing LESS-P and learning the Cross-technique. The laceration required no additional procedures and the patient recovered uneventfully. Moreover, when PST performed laparoscopic pyloromyotomies, no serosal lacerations occurred. This confers LP a technical advantage over OP, as stated already previously by other authors [2,3]. In the OPs that were evaluated for our study, 3 (3.7%) serosal lacerations were recorded for PST, but also 2 (3.3%) serosal lacerations for BC. LP apparently showed the same rate of wound infections as OP but all wound infections in LP were associated with the use of skin adhesives, whereas wound infections in OP occurred independently of skin adhesives. We initially chose to close the skin in LP using skin adhesives, as LP is considered a clean procedure and data from pediatric inguinal herniorrhaphies reported a faster time for skin closure without an increased rate of wound infections [12]. One possible explanation for the wound infections encountered while using skin adhesives might be that after recent umbilical cord separation in newborns, debris and bacteria are located in the moist and dirty folds of the umbilicus [13], and that sealing this area with the skin adhesive might contribute to accumulation of bacteria on the fresh wound. In consequence, we recommend not to use skin adhesives for the closure of the umbilical wound after LP. While a systematic review and meta-analysis of LP vs. OP associated a lower rate of wound complications with LP [14], other studies did not find a significant difference [2,7]. In fact, when not using skin adhesives, we did not encounter a single wound infection in LP. The observation that PST operate less laparoscopic pyloromyotomies than OP as stated by Hall et al. 2009 [2] holds true in our study during the initial transition period from OP to LP. We chose to let BC operate during this transition period as data from the literature [7,15] suggested this period to be vulnerable to more complications. Accordingly, in our setting, we chose BC to perform an average of 10 3TP before assigning the procedure to PST. When PST were trained by those BC to perform 3TP, no intraoperative complications occurred. However, during time, when observing PST performing 3TP, we felt that they intuitively coped very well with the new method and that PST could be allowed earlier to participate in LP. Accordingly, we chose to distribute LESS-P to PST after only an average of 4 procedures had been trained by the assisting BC, obtaining equally good results. As stated by other authors [16,17], we found LESS-P to be a practicable procedure with a similar outcome as 3TP. In fact, during the last time period of the study, PST performed almost the same percentage of LP than BC, confirming the published data by Hall et al. in 2014 [5], that in most teaching centers, PST perform
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nowadays an equal amount of LP as BC. In our study, LP seems to be the safer procedure than OP in the hands of PST with regard to mucosa perforations and serosal lacerations and is in accordance with the above mentioned recent study by Hall et al. 2014 [5], which states that the grade of the primary operator does not lead to a higher rate of complications in LP. 4. Conclusions The presented algorithm effectively prevented incomplete LP. The algorithm was successful both when BC learned it during the transition period from OP to LP, and during the subsequent training of PST. The algorithm proved to be simple to be performed in two different LP techniques. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.jpedsurg.2014.12.004. References [1] Carrington EV, Hall NJ, Pacilli M, et al. Cost-effectiveness of laparoscopic versus open pyloromyotomy. J Surg Res 2012;178:315–20. [2] Hall NJ, Pacilli M, Eaton S, et al. Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: a double-blind multicentre randomised controlled trial. Lancet 2009;373:390–8. [3] St Peter SD, Holcomb III GW, Calkins CM, et al. Open versus laparoscopic pyloromyotomy for pyloric stenosis: a prospective, randomized trial. Ann Surg 2006;244:363–70. [4] Siddiqui S, Heidel RE, Angel CA, et al. Pyloromyotomy: randomized control trial of laparoscopic vs open technique. J Pediatr Surg 2012;47:93–8. [5] Hall NJ, Eaton S, Seims A, et al. Risk of incomplete pyloromyotomy and mucosal perforation in open and laparoscopic pyloromyotomy. J Pediatr Surg 2014;49:1083–6. [6] Muensterer OJ, Chong AJ, Georgeson KE, et al. The Cross-technique for singleincision pediatric endosurgical pyloromyotomy. Surg Endosc 2011;25:3414–8. [7] Adibe OO, Nichol PF, Flake AW, et al. Comparison of outcomes after laparoscopic and open pyloromyotomy at a high-volume pediatric teaching hospital. J Pediatr Surg 2006;41:1676–8. [8] Yagmurlu A, Barnhart DC, Vernon A, et al. Comparison of the incidence of complications in open and laparoscopic pyloromyotomy: a concurrent single institution series. J Pediatr Surg 2004;39:292–6. [9] Ostlie DJ, Woodall CE, Wade KR, et al. An effective pyloromyotomy length in infants undergoing laparoscopic pyloromyotomy. Surgery 2004;136:827–32. [10] Campbell BT, McLean K, Barnhart DC, et al. A comparison of laparoscopic and open pyloromyotomy at a teaching hospital. J Pediatr Surg 2002;37:1068–71. [11] Oomen M, Bakx R, Peeters B, et al. Laparoscopic pyloromyotomy, the tail of the learning curve. Surg Endosc 2013;27:3705–9. [12] Brown JK, Campbell BT, Drongowski RA, et al. A prospective, randomized comparison of skin adhesive and subcuticular suture for closure of pediatric hernia incisions: cost and cosmetic considerations. J Pediatr Surg 2009;44:1418–22. [13] Katz MS, Schwartz MZ, Moront ML, et al. Prophylactic antibiotics do not decrease the incidence of wound infections after laparoscopic pyloromyotomy. J Pediatr Surg 2011;46:1086–8. [14] Sola JE, Neville HL. Laparoscopic vs open pyloromyotomy: a systematic review and meta-analysis. J Pediatr Surg 2009;44:1631–7. [15] Oomen MW, Hoekstra LT, Bakx R, et al. Learning curves for pediatric laparoscopy: how many operations are enough? The Amsterdam experience with laparoscopic pyloromyotomy. Surg Endosc 2010;24:1829–33. [16] Kozlov Y, Novogilov V, Podkamenev A, et al. Single-incision laparoscopic surgery for pyloric stenosis. Pediatr Surg Int 2012;28:347–50. [17] Li B, Chen WB, Wang SQ, et al. Single-site umbilical laparoscopic pyloromyotomy in neonates less than 21-day old. Surg Today 2015;45:29–33. http://dx.doi.org/10. 1007/s00595-014-0854-z.
Please cite this article as: Vahdad MR, et al, Can a simplified algorithm prevent incomplete laparoscopic pyloromyotomy?, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.12.004