Laparoscopic Pyloromyotomy

This video will demonstrate a laparoscopic pyloromyotomy in an 8 week old girl. The patient presented with classic symptoms of pyloric stenosis. Her ultrasound demonstrated all the criteria of pyloric stenosis, namely, a muscle limb thicker than 4 millimeters, a channel longer than 17 millimeters, and pyloric muscle shouldering. After appropriate resuscitation and correction of metabolic abnormalities, a laparoscopic pyloromyotomy was performed. The patient is positioned perpendicular to the axis of the operating table with the operating team at the patient's feet as shown. A 5 millimeter trocar is placed at the umbilicus for the camera. Stab incisions are used for the operating instruments. Strategic placements of these incisions optimizes performance of the procedure. The right upper quadrant incision is placed at or just above the liver margin. The instrument placed through this incision will help retract the liver edge, if needed. The left upper quadrant incision is placed in a high paramedian position to allow the spreader to approach the pyloris directly rather than tangentially. An intraabdominal pressure of 10 millimeters of mercury and a flow rate of 1.5 L per minute are used throughout the procedure. The flow rate may be increased if there is a leak around the stab incisions. The entry sites and positioning of this patient are shown here. A perfect alignment of the operating team, surgical site, and video screens are obtained in this setup. An 11 blade is used to make the left upper quadrant stab incision. A long cautery with a protected blunt tip is introduced. The extents of the thickened muscle are palpated with the cautery tip from the indentation proximally to the vein of mayo or junction of the white colored wall of the stomach and the salmon colored wall of the duodenum distally. Coagulation is then used to mark the palloromyotomy line between the proximal and distal extents. The surgeon should not extend the myotomy beyond these originally labeled extents. The cutting current is then used to initiate the myotomy along the marked line. Coagulation should not be used for the myotomy in order not to transmit heat to the underlying mucosa. The myotomy is subsequently deepened 2 to 3 millimeters in the same fashion. The cautery tip is then turned 90 degrees a few times to create a space for the spreader. The myotomy should be 2 to 3 millimeters deep before the beginning of muscle spreading. Deepening the myotomy should always start in the center or proximal extent, never on the duodenal end. The straight laparoscopic spreader is then used to continue the procedure. A single blade is inserted first, followed by both blades. A controlled but deliberate force should be applied to spread the muscle. The surgeon should observe the muscle layer separating, resulting in visualization of the underlying submucosa. Again, the myotomy should start in the middle. The procedure is then continued proximately towards the stomach. And distally towards the duodenum. I prefer to use the right angle spreader on the last few fibers on the duodenal end. The heel of the instrument protects the mucosa while the tip spreads the muscle. One should not insist on separating the last few fibers on the duodenal end if the pylorus is stiff, as this is the point at which a duodenal perforation may occur. Incomplete myotomies occur on the gastric, not the duodenal end. The procedure is concluded by confirmation of the adequacy of the myotomy and integrity of the duodenal mucosa. An adequate myotomy should allow each limb of the muscle to move independent of the other. Intact duodenal mucosa is best proven by direct visualization. A Q-tip can be introduced to wipe any blood on the mucosa and allow the surgeon to clearly examine it. The duodenal bulb is occluded, and the stomach is insufflated with 30 mL of air through an orogastric tube. The myotomy site is examined, while pressure is applied to the antrum, again, to look for an air leak. However, it must be emphasized that this is less important than direct visualization. The myotomy site is then covered by an omental pedicle. The stomach is then aspirated and orogastric tube removed. A missed duodenal perforation is the most serious complication of a laparoscopic palloromyotomy. Let us review the essential steps in the performance of a safe procedure. The instruments should be placed strategically to retract the liver if needed, and approach the pyloris directly. The proximal extent of the myotomy should be delineated and marked with cautery. The surgeon should avoid the temptation to extend the myotomy past these markings, particularly on the duodenal side. A few intact muscle fibers may be left on the pyloo duodenal junction. The myotomy should be commenced with cutting current and completed with spreaders, always starting at the center. The right angle spreader may afford additional safety on the duodenal side. The integrity of the mucosa should be confirmed by direct visualization.