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Trocarless Laparoscopic Pyloromyotomy with Conventional Instruments: Our Experience 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
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