Original Article

Trocarless laparoscopic pyloromyotomy with conventional instruments: Our experience

Sandesh V Parelkar, Pooja V Multani, Beejal V Sanghvi, Shishira R Shetty, Hemangi R Athawale, Satish P Kapadnis, Dinesh D Mundada, Sanjay N Oak Department of Pediatric Surgery, KEM Hospital, Parel, Mumbai, India

Address for Correspondence: Dr. Pooja Multani, Department of Pediatric Surgery, Old Building, King Edward Memorial Hospital, Parel - 400012, Mumbai, India. E-mail: [email protected]

Abstract INTRODUCTION

BACKGROUND: The incidence of hypertrophic pyloric Hypertrophic pyloric stenosis (HPS) is a common problem stenosis is approximately 1–3 per 1,000 live births. encountered during infancy. The Ramstedt pyloromyotomy, Hypertrophic pyloric stenosis is seen more often in developed in 1911, remains the standard treatment for this males, with a male-to female ratio of 4:1. Laparoscopic condition. Laparoscopic pyloromyotomy was introduced in pyloromyotomy is becoming increasingly popular as the 1991 by Alain and Grousseau.[1] However, the risk of duodenal standard treatment for hypertrophic pyloric stenosis. injury has deterred many surgeons from using this method.[1] MATERIALS AND METHODS: We describe our initial Since then, studies have shown better cosmesis and similar experience with laparoscopic pyloromyotomy in 16 complication rates compared with open pyloromyotomy.[2,3] infants using conventional laparoscopic instruments. The aim of this study was to assess the safety and potential Laparoscopic pyloromyotomy was performed through benefits of laparoscopic pyloromyotomy for infantile HPS 5-mm umbilical port with 5mm 30 endoscope. Two in our hospital using conventional trocarless working 3-mm working instruments were inserted directly into the instruments. This report describes the technique, challenges, abdomen via separate lateral incisions. RESULTS: All and outcomes of our first 16 procedures. patients were prospectively evaluated. The procedure was performed in 16 infants with a mean age of 36 days and mean weight of 3.1 kg. All procedures, except two, were MATERIALS AND METHODS completed laparoscopically with standard instruments. Average operating time was 28 mins, and average Sixteen infants with diagnosis of HPS were treated over a postoperative length of stay was 2.8 days. There were period of 2 years from June 2010 to June 2012. All patients no major intraoperative and postoperative complications. were evaluated with X-ray abdomen erect and ultrasonography. CONCLUSION: Laparoscopic pyloromyotomy can Diagnostic criteria used were clinical history of gastric be safely performed by using standard conventional vomiting, palpable olive and radiological evidence of pyloric laparoscopic trocarless instruments. length of more than 18mm and thickness of ≥4 mm.[4]

Key words: Conventional instruments, laparoscopic, After admission and stabilization of electrolyte and acid pyloromyotomy, trocarless base balance, the infants were posted for laparoscopic pyloromyotomy.

Access this article online Ergonomics Quick Response Code: Website: www.journalofmas.com The infant was placed in the supine position. The surgeon, the assistant and the scrub nurse stood on left side of patient with the monitor at the head end towards the right side. DOI: 10.4103/0972-9941.118831 Surgical Technique Patients received one dose of perioperative antibiotic

Journal of Minimal Access Surgery | October-December 2013 | Volume 9 | Issue 4 159 Parelkar, et al.: Trocarless laparoscopic pyloromyotomy

Figure 1: Initial incision Figure 2: Complete pyloromyotomy before the procedure. A 5-mm port was inserted through a RESULTS subumbilical incision. Pneumoperitoneum was created by open Hasson’s technique. Insufflation of CO2 was started at Of the 16 cases 14 were males and two were females (Male: 0.1litre/min and increased till 1litre/min. Pressure was kept at Female ratio 7:1) aged 3-12 weeks, (average 36 days). Weight around 6mmHg and was increased to maximum of 8 mmHg, if at admission ranged from 2.3-3.5 kg (average 3.1 kg). needed. Two 3 mm instruments were passed directly through Duration of illness ranged from 3 to 16 days (average 6 days). the incisions, one in the right anterior axillary line slightly above the level of the umbilicus to grasp the stomach and the The most common presentation was nonbilious vomiting. other in the epigastric region directly over the pylorus, used for History of constipation was reported in 10 (62.5%) patients. incising and splitting of the pylorus. The stomach was pulled Metabolic disturbances that needed correction were reported in 9 (56.25%) patients. Fourteen procedures were to the left to visualize the pylorus. Before each procedure, completed laparoscopically and two required conversion, one insulation of hook was checked by thorough inspection. for suspected inadequate pyloromyotomy and another for An incision was made along the thickened pylorus from the mucosal perforation (conversion rate 6.25%). For inadequate stomach to the duodenum using 3 mm hook with monopolar pyloromyotomy, a complete pyloromyotomy was done by coagulating current of 30 Watts [Figure 1]. The incision was open technique. For mucosal perforation, which was at the deepened. At times, when the coagulating current was not gastric end of the pyloromyotomy, suturing was done by open enough, minimum cutting current was used to complete the technique. Both conversions occurred early in the series. No incision (30 Watts). The 3 mm Maryland forceps were used to conversions occurred in the last 13 cases. For analysis of data further split the hypertrophied muscle fibers until mucosa was of postoperative stay and time to tolerate full feeds, the infant visualized and spread [Figure 2]. A satisfactory pyloromyotomy with mucosal perforation was excluded. Average operating was confirmed by ballooning out the intact mucosa and time was 28 mins (Range 18-38 mins). Average postoperative two separate independently moving pyloric edges. Mucosal length of stay was 2.8 days (Range 1.8-3.6 days). All infants, except one with mucosal perforation, were started on full perforation was excluded by insufflating the stomach with air feeds after 12 hours and were discharged on full feeds. A via the nasogastric tube (NGT). mean of 27 hours (16-45 hours) was reported for the time to reach full feeds. The 5 mm umbilical port site was closed with an absorbable suture and the skin of all wounds was reapproximated with No postoperative complications were noted in any of the an adhesive glue. NGT was removed on the table. infants. One child had prolonged postoperative emesis and was managed conservatively. On followup, all infants Postoperative had gained weight and were thriving well. All infants were Feeds were gradually introduced after 12-18 hours. The reexamined 3 months after the surgery. It was difficult to infants were normally discharged the day after tolerating identify the 3-mm-direct instrument insertion site in the full feeds. abdominal wall [Figure 3].

160 Journal of Minimal Access Surgery | October-December 2013 | Volume 9 | Issue 4 Parelkar, et al.: Trocarless laparoscopic pyloromyotomy

and pyloromyotomy was completed with use of arthroscopy knife and specialized laparoscopic pyloric spreader and with a reported mean operating time of 29 ± 8.3 minutes and wound complications was reported in 4.3% patient. Harris and Cywes[13] presented a simple technique and used extended tip cautery and 2 reusable, laparoscopic pyloric spreaders. Daniel et al.,[5] used arthroscopy knife and pyloric spreader and reported average operating time of 24 ± 8 minutes and wound infections in 1.17% patients.

In 2004, a meta-analysis of reported studies by Hall[6] was unable to show a clear benefit of laparoscopic approach over the open technique. However, in a recent study conducted by, [14] Figure 3: Post-operative Sola and Neville in 2009 which derived meta-analysis of data from five level 1 studies and one level 2 study, concluded that the laparoscopic approach yields a DISCUSSION significantly reduced rate of total complications. Recently, advances in the laparoscopic technique have been reported Surgical treatment of HPS was first described by Fredet and by Salmai et al.,[7] by using 2.4 mm scope with 2mm direct Lesne in 1907. The extramucosal pyloromyotomy was further instruments in 21 patients with average operating time of refined by Ramstedt and it is considered to be one of the most 13 minutes and use of high powered monopolar cautery consistently successful operations in the armamentarium (2.5 times higher than recommended by the electrocautery [9] of Pediatric Surgeons. Despite the success, the procedure device manager). The author reported longer postoperative still has morbidity of up to 16%, mostly due to difficulty stay (87 hours) and also reduced illumination as problems [10] [11] with postoperative emesis or wound complications with this technique. Open approaches for HPS include median longitudinal incision, Robertson muscle splitting incision, Randolph’s We report the use of conventional laparoscopic trocarless tranverse right upper quadrant incision and Tan and working instruments and almost similar results as compared [12] Bianchi’s circumumbilical incision. AR Khan et al., observed to various authors summarized in table above [Tables 1 and 2]. 39 patients operated with circumumbilical incision and In fact, our most efficient laparoscopic time was only 18 mins. concluded that this technique results in increased operative Use of trocar-less instruments also reduces the incision time (28 minutes), more gastric manipulation (33% requiring size thus making it cosmetically appealing as compared extension of incision), higher wound infections (5.12%) and to the conventional open pyloromyotomy. Retractable longer gastric atony (15.3%). pyloromyotomy knives, laparoscopic pyloric spreader, an arthrotomy knife, myringotomy knife, indigenous knife Video-assisted, minimally-invasive surgery is increasingly placed in a laparoscopic needle holder have been used for accepted in the pediatric population as more experience is performing laparoscopic pyloromyotomy by various authors. gained and instruments become more refined. Laparoscopic The use of cautery for deepening the incision has a risk of pyloromyotomy was first described in 1991 by Alain injury to the mucosa but with judicious use and proper et al.[1] Since then, several other groups have reported pre-procedure checking of the intact insulation minimizes their experience with laparoscopic pyloromyotomy and this risk. Hence the fear associated with the use of cautery also suggested technical improvements in the procedure. is ought to be virtual and not real. The chance of injury Rothenberg described his slice and pull technique in 1997 to the mucosa was minimal. The hook could therefore be where he grasped the duodenum with laparoscopic Babcock’s inserted liberally in the pylorus to divide the muscle at depth. clamp and reported an average operating time of 13 minutes. Complete separation of the hypertrophied muscle could then All the reported techniques describe grasping and cutting easily be achieved using a 3 or 5 mm Maryland forceps. from the duodenum toward the stomach. This increases the risk of tearing or perforating the duodenum, and has Jain et al.,[8] reported the use of conventional instruments deterred some surgeons from attempting the laparoscopic (n = 15). They compared conventional and special technique. Bufo et al.,[11] described a safer technique in instruments (n = 12) and concluded similar results and lesser which the stomach rather than the duodenum was grasped bleeding with the former.

Journal of Minimal Access Surgery | October-December 2013 | Volume 9 | Issue 4 161 Parelkar, et al.: Trocarless laparoscopic pyloromyotomy

Table 1: Comparison of technique with other studies Comparison Ostlie et al.[5] Hall et al.[6] 2004 Leclair et al.[2] Salmai et al.[7] Jain et al.[8] 2012 Present series of technique 2004 (n=121) (n=39) 2007 (n=50) 2011 (n=21) (n=27) (n=16) Mean Operating 30 min 50 min 35 min 13 min 40 min/38 min 28 min time Conversions to an nil 8% 6% nil 0% 6.25% open procedure Incomplete nil 8.3% 6% nil nil 6.25% pyloromyotomy Ports and 3 ports-5,3,3 mm 3 ports-3 mm 3 ports-5,3,3 1.9 mm, Knife/monopolar 5,3,3 mm Hook with instruments Arthroscopy knife each Tan Endoscopic Pyloromyotomy hook and cautery diathermy (conventional endotome spreader knife instruments)

Table 2: Comparison of complications with other studies Complications Ostlie et al.[5] Hall et al.[6] Leclair et al.[2] Salmai et al.[7] Jain et al.[8] Present series 2004 (n=121) 2004 (n=39) 2007 (n=50) 2011 (n=21) 2012 (n=27) (n=16) Mucosal perforation 1.2% 6% 2% nil nil 6.25% Duodenal perforation nil 5% 2% nil nil nil Wound infection 1.16% 3% 2% nil nil nil Time to reach full feeds 20 hrs 23.3 hrs 34 hrs 24 hrs 24.5 hrs/23.8 hrs 27 hrs Prolonged emesis nil 8.3% 26% 9.52% 25%/33% 6.25% Postoperative stay 32 hrs 48 hrs 22 hrs 87hrs 35.6 hrs/36 hrs 54 hours

No wound infections occurred in our laparoscopic group. 3. St Peter SD, Holcomb GW 3rd, Calkins CM, Murphy JP, Andrews WS, Sharp Our technique of laparoscopic pyloromyotomy is a safe RJ, et al. Open versus laparoscopic pyloromyotomy for pyloric stenosis: A prospective, randomized trial. Ann Surg 2006;244:363-70. procedure that is as effective as the “gold standard’’ 4. Haller JO, Cohen HL. Hypertrophic pyloric stenosis: Diagnosis using US. conventional open Ramstedt’s pyloromyotomy to treat Radiology 1986;161:335-9. HPS and results in a better cosmetic appearance than the 5. Ostlie DJ, Woodall CE, Wade KR, Snyder CL, Gittes GK, Sharp RJ, et al. An effective pyloromyotomy length in infants undergoing laparoscopic open procedures. pyloromyotomy. Surgery 2004;136:827-32. 6. Hall NJ, Pacilli M, Eaton S, Reblock K, Gaines BA, Pastor A, et al. Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: A double- CONCLUSIONS blind multicentre randomized controlled trial. Lancet 2009;373:390-8. 7. Turial S, Enders J, Schier F. Microlaparoscopic pyloromyotomy in children: Laparoscopic pyloromyotomy was performed safely and Initial experiences with a new technique. Surg Endosc 2011;25:266-70. 8. Jain V, Choudhury RS, Chadha R, Puri A, Naga AS. Laparoscopic successfully using standard conventional laparoscopic pyloromyotomy: Is a knife really necessary. World J Pediatr 2012;8:57-60. trocarless instruments. Use of trocarless instruments is safe, 9. Raffensperger J. Pierre Fredet and pyloromyotomy. J Pediatr Surg effective and reduces incision size, improving cosmesis. We 2009;44:1842-5. 10. Spitz L. Vomiting after pyloromyotomy for infantile hypertrophic pyloric strongly recommend pre-procedure checking the insulation stenosis. Arch Dis Child 1979;54:886-9. of these instruments. 11. Bufo AJ, Merry C, Shah R, Cyr N, Schropp KP, Lobe TE. Laparoscopic pyloromyotomy: A safer technique. Pediatr Surg Int 1998;13:240-2. 12. Khan AR, Al-Bassam AR. Circumumbilical pyloromyotomy: Larger pyloric We conclude that use of conventional trocarless working tumours need an extended incision. Pediatr Surg Int 2000;16:338-41. laparoscopic instruments for laparoscopic pyloromyotomy 13. Harris SE, Cywes R. Laparoscopic pyloromyotomy. Pediatr Endosurg Innov Tech 2001;15:405-10. is better cosmetically and is comparable with other studies 14. Sola JE, Neville HL. Laparoscopic vs open pyloromyotomy: A systematic and conventional open pyloromyotomy. review and meta-analysis. J Pediatr Surg 2009;44:1631-7.

REFERENCES Cite this article as: Parelkar SV, Multani PV, Sanghvi BV, Shetty SR, Athawale HR, Kapadnis SP, Mundada DD, Oak SN. Trocarless laparoscopic 1. Alain JL, Grousseau D, Terrier G. Extramucosal pylorotomy by laparoscopy. pyloromyotomy with conventional instruments: Our experience. J Min Access J Pediatr Surg 1991;26:1191-2. Surg 2013;9:159-62. 2. Leclair MD, Plattner V, Mirallie E, Lejus C, Nguyen JM, Podevin G, et al. Date of submission: 24/11/2012, Date of acceptance: 22/01/2013 Laparoscopic pyloromyotomy for hypertrophic pyloric stenosis: A prospective, randomized controlled trial. J Pediatr Surg 2007;42:692-8. Source of Support: Nil, Conflict of Interest: None declared.

162 Journal of Minimal Access Surgery | October-December 2013 | Volume 9 | Issue 4 Copyright of Journal of Minimal Access Surgery is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.