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Laparoscopic Pyloromyotomy George W. Holcomb, III, M.D., MBA Childrens Mercy Hospital Kansas City, Missouri.

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Presentation on theme: "Laparoscopic Pyloromyotomy George W. Holcomb, III, M.D., MBA Childrens Mercy Hospital Kansas City, Missouri."— Presentation transcript:

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

2 Preoperative Evaluation Pyloric Stenosis Non-bilious emesis 2-8 wks of age Male:Female4:1 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, 70 o 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 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 A Pyloric (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 Intraoperative and Postoperative Data Comparison CharacteristicLAP (n=51) RUQ (n=190) UMB (n=49) p Value Operating room time (min) 71 ± ± ± 15 < Operative time (min)25 ± 9 32 ± 9 42 ± 11< Postoperative length of stay (d) 1.8 ± 11.6 ± 11.8 ± Time to ad lib feedings (h) 26 ± 2222 ± 1426 ± Conversion rate (%)2/51 (4) JACS 201:66-70, 2005

13 Retrospective Review – Laparoscopic, Circumumbilical and RUQ Approaches Intraoperative and Postoperative Data Comparison CharacteristicLAP (n=51) RUQ (n=190) UMB (n=49) p Value Complication rate (%) Mucosal perforation033 Wound infection0113 Wound dehiscence111 Incisional hernia020 Persistent emesis120 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 Childrens 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 Results October 1999 – October infants Mean age – 5.2 wks (± 2.8) Ultrasound Mean length– ± 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 Results 171 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 The Center for Prospective Clinical Trials Childrens Mercy Hospital Kansas City, MO 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

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

23 Methods Sample Size Mean operative times were utilized from retrospective data within our institution Power = 0.80 and α = 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 Interventions Open 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 Interventions Laparoscopic Pyloromyotomy 5 mm port in umbilicus 2 stab incisions right and left upper quadrants 3 mm instruments Grasper in surgeons left hand Blade followed by spreader in surgeons right hand

28 Management Diet 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 Management Pain 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 Students t- test Discrete variables were analyzed with Fishers exact test Significance was defined as P value < of 0.05 All measures evaluated on intention-to-treat basis

32 Results Upon Presentation OPEN (n = 100) LAP () LAP (n = 100) Age (weeks) / / P Value Thickness (mm) / / Length (mm) / / Cl - (mmol/L) / / HCO3 - (mmol/L) / / (Mean +/- S.E.) ( Mean +/- S.E.)

33 Results Outcomes OPEN () OPEN (n = 100) LAP (n = 100) P Value OR time (mins) 19:28 +/ :34 +/ Emesis (#) / / Full Feeds (hrs) 21:01 +/ :30 +/ LOS (hrs) 33:10 +/ :38 +/ Tylenol ( doses) / / (Mean +/- S.E.) ( Mean +/- S.E.)

34 Results Complications 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 Results Cosmetic Outcome OPEN OPEN LAP 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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