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

2. 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
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 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. Intraoperative and Postoperative Data Comparison
Retrospective Review – Laparoscopic, Circumumbilical and RUQ Approaches
Intraoperative and Postoperative Data Comparison
Characteristic
LAP (n=51)
RUQ (n=190)
UMB (n=49)
p Value
Operating room time (min)
71 ± 13□
74 ± 14†
83 ± 15‡
<0.0001
Operative time (min)
25 ± 9□ ‡
32 ± 9†
42 ± 11
Postoperative length of stay (d)
1.8 ± 1
1.6 ± 1
0.26
Time to ad lib feedings (h)
26 ± 22
22 ± 14
26 ± 19
0.07
Conversion rate (%)
2/51 (4)
JACS 201:66-70, 2005

13. Intraoperative and Postoperative Data Comparison
Retrospective Review – Laparoscopic, Circumumbilical and RUQ Approaches
Intraoperative and Postoperative Data Comparison
Characteristic
LAP (n=51)
RUQ (n=190)
UMB (n=49)
p Value
Complication rate (%) 4 10 14
0.23
Mucosal perforation 3
Wound infection 11
Wound dehiscence 1
Incisional hernia 2
Persistent emesis
JACS 201:66-70, 2005

14. Children’s Mercy Hospitals and Clinics
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. Results October 1999 – October 2003
171 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 Length of myotomy
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
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
Doxepin hydrochloride is a psychotherapeutic agent in the class of dibenzoxepin tricyclic compounds
Ann Surg 244: , 2006

23. Methods Sample 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
These two medications are not only complimentary in their coverage, but they are chemically compatible with well-documented stability allowing for storage in the same bag, simultaneous administration, or successive administration through the same line

24. Assignment Individual unit randomization sequence Non-stratified
Blocks of 10
Allotment obtained from randomization sequence after permission form signed
These two medications are not only complimentary in their coverage, but they are chemically compatible with well-documented stability allowing for storage in the same bag, simultaneous administration, or successive administration through the same line

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
These two medications are not only complimentary in their coverage, but they are chemically compatible with well-documented stability allowing for storage in the same bag, simultaneous administration, or successive administration through the same line

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
Benson muscle spreader

27. Interventions Laparoscopic 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
These two medications are not only complimentary in their coverage, but they are chemically compatible with well-documented stability allowing for storage in the same bag, simultaneous administration, or successive administration through the same line

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
These two medications are not only complimentary in their coverage, but they are chemically compatible with well-documented stability allowing for storage in the same bag, simultaneous administration, or successive administration through the same line

29. Management Pain Control
Acetaminophen (10mg/kg) PO/PR every 4 hours as needed for pain
No patients received narcotics
These two medications are not only complimentary in their coverage, but they are chemically compatible with well-documented stability allowing for storage in the same bag, simultaneous administration, or successive administration through the same line

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
These two medications are not only complimentary in their coverage, but they are chemically compatible with well-documented stability allowing for storage in the same bag, simultaneous administration, or successive administration through the same line

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
These two medications are not only complimentary in their coverage, but they are chemically compatible with well-documented stability allowing for storage in the same bag, simultaneous administration, or successive administration through the same line

32. Results Upon Presentation
OPEN (n = 100)
LAP (n = 100)
P Value
(Mean +/- S.E.) (Mean +/- S.E.)
Age (weeks) / /- 0.22
0.77
0.88
0.74
0.72
0.65
Thickness (mm) / /- 0.09
Length (mm) / /- 0.27
Therefore we were comparing about 3.5 yrs experience against 1.5 yrs experience
Cl - (mmol/L) / /- 0.79
HCO3 -(mmol/L) / /- 0.49

33. Results Outcomes OPEN (n = 100) LAP (n = 100) P Value 0.93
(Mean +/- S.E.) (Mean +/- S.E.)
OR time (mins) 19:28 +/ :34 +/- 0.78
Emesis (#) / /- 0.23
Full Feeds (hrs) 21:01 +/ :30 +/- 1.46
LOS (hrs) 33:10 +/ :38 +/- 1.69
Tylenol (doses) / /- 0.16
0.93
0.05
0.43
0.12
0.01
Therefore we were comparing about 3.5 yrs experience against 1.5 yrs experience

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)
This mucosal perforation was recognized at the time of surgery and repaired without effect
This hernia required operative repair
Wound infection was defined as requiring drainage or antibiotics prescribed by one of the participating surgeons

35. Results Cosmetic Outcome
OPEN
LAP
Some examples of open pyloromyotomy
Several yrs out
1 yr out
Preop photos several months later on the 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
Therefore we were comparing about 3.5 yrs experience against 1.5 yrs experience

37. Conclusions
All surgeons confirmed they will perform the pyloromyotomy with the laparoscopic approach
Therefore we were comparing about 3.5 yrs experience against 1.5 yrs experience

38. ? ? ?
Dr Ostlie, the PI of this study will address your questions