Incision

Usually performed through a small (6-8 cm) upper midline incision but can be performed through a upper left lateral horizontal incision also.

Surgical Details of the Procedure

1. The incision is made in the skin with a No. 10 blade.

2. Dissection is done through the subcutaneous tissue with Bovie electrocautery.

3. The midline (if vertical incision is used) is found and carefully incised with a knife or Bovie cautery.

4. The preperitoneal fat is retracted upwards with forceps on either side of the midline and incised carefully using Bovie cautery.

5. The peritoneum is grasped with forceps on either side of the midline and incised with a Metzenbaum scissors.

6. The abdominal cavity is entered with care taken to take down any adhesions to the inner abominal wall with gentle traction and using the Metzenbaum scissors.

7. Babcock clamps are used to grasp the anterior stomach wall in the mid to slightly distal stomach and to elevate it into the wound.

8. A circular purse-string suture is placed with a diameter of 1.5 – 2.0 cm using a 2-0 or 3-0 silk suture with the ends left untied.

9. A concentric purse-string of 2-0 or 3-0 silk is then placed just outside of the first purse-string with the ends left untied.

10. A small opening is made in the serosa of the stomach in the center of the two concentric pursestring sutures, usually by placing the Bovie cautery onto the surface for a second.

11. A hemostat is used to grasp the inner mucosal layer of the stomach and to pull it up through the opening made in the serosa.

12. This lip of mucosa is then amputated using the Bovie cautery.

13. The hole in the anterior stomach is widened slightly by placing the tips of a closed hemostat into the hold and then spreading.

14. A 18-22 French Foley balloon catheter is then placed into the stomach through the just made opening.

15. The balloon is inflated and then pulled up tight against the inner surface of the stomach.

16. First the inner and then the outer sutures are cinched down and tied.

17. The stomach with the protruding Foley catheter is them moved up against the inside of the abdominal wall to see where the exit site of the Foley should be positioned.

18. A stab wound is made in the skin with a No. 11 blade.

19. Bovie cautery is used to control and skin bleeding.

20. A Schnitt forceps is bluntly forced through the stab wound into the abdominal cavity and the tips are opened.

21. The Foley catheter is fed onto one of the tips and the forceps is closed and pulled back out of the abdominal cavity, bringing the Foley catheter with it.

22. The inside anchoring sutures are then placed. This is done by first placing a silk suture through the stomach mucosa and then through the tissue on the underside of the abominal wall, but is left untied. Usually the “back” suture is place first (i.e., the suture that is on the other side of the Foley).

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Indications

Congenital hypertrophic pyloric stenosis – this condition occurs in infants and is marked by a thickening of the pylorus which is the muscular band of tissue in the stomach that controls the exit of food and gastric juices from the stomach.

Diagnosis

Projectile vomiting – this vomiting occurs after feeds and is first seen in infants several weeks after birth. To experienced clinicians this alone is highly suggestive of this condition

Presence of an “olive” on palpation – often the hypertrophic (overgrown) pylorus muscle can be palpated (felt) on exam by an experienced surgeon. It literally feels like an olive in the right upper quadrant beneath the right costal margin (right rib cage) when direct, firm pressure is placed.

Pre-operative Workup and Preparation

Correction of electrolyte imbalance – infants with pyloric stenosis and vomiting typically have derangements of serum electolytes such as low potassium and magnesium.

Correction of fluid balance – this is done through an intravenous line inserted peripherally and an infusion of 5% dextrose in normal saline usually at the rate of 10ml/Kg. This is considered maintenance fluid. Any preceding fluid deficit is then made up by using 5% dextrose in alternating solutions of normal saline and water for 12-24 hours or until adequate urine output has been established.

Correction of acid/base balance – this usually occur with correction of the fluid deficit and potassium loss.

Placement of nasogastric tube – after the diagnosis the infant oral feeds for the infant are suspended. Although prolonged placement of a nasogastric tube is to be avoided, sometimes 6-12 hours is needed to prevent further vomiting.

Incision

Surgical Details of the Procedure

1. A small 3 cm incision is made in the skin with a No. 15 blade just below the right costal margin (the right rib cage) on the anterior abdominal wall, but above the inferior edge of the liver.

2. Care must be taken to place the incision so that it extends laterally from the outer edge of the rectus muscle.

3. Dissection is done through the subcutaneous tissues with Bovie cautery.

4. The muscle layer is carefully divided using Bovie cautery with the omentum or transverse colon presenting into the wound.

5. Using very gentle traction on the omentum the transverse colon if not already visualized through the wound can be presented up into the wound.

6. Gentle traction on the transverse colon will then deliver the greater curvature of the stomach up into the wound.

7. The anterior wall of the stomach is grasped with a moist sponge and gentle traction on the stomach antrum is applied – this will deliver the pylorus into the wound.

8. The avascular (without blood supply) portion of the anterior wall of the pylorus is identified.

9. The pylorus is held between the surgeons thumb and forefinger and a 1-2 cm longitudinal incision (along the plane of the pylorus) is made.

10. The incision is taken down through the serosal and muscle layers until the mucosa is exposed.

11. Great care must be taken not to incise the mucosa. Extra attention must be given to the duodenal end of the incision as the muscle layer ends abruptly.

12. The incised (cut) muscle is gently spread apart with a hemostat until the mucosa “puffs up” to the level of the cut serosa.

13. The peritoneum and fascia of the transversalis muscle is closed with a running absorbable suture.

14. The remaining fascial layers are closed with either running or interrupted slowly absorbable sutures.

15. The skin is closed with a subcuticular absorbable suture such as Monocryl.

16. Collodian or adhesive Steri-strips are placed on the wound.


Copyright 2007 InsideSurgery.com

Laparoscopic Technique

Surgical Details of Procedure

1. A 10 mm incision is made in the supraumbilical area.

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Indications

Feeding – there are several groups of patients that receive PEG tubes. One group is patients with disruption, obstruction (from cancer), or malfunction (achalasia, multiple sclerosis, scleroderma) of the esophagus. Patients with severe head trauma with residual deficits at risk of aspiration are candidates. Additional patients who can not take normal feeds and may require PEG tubes are patients on the ventilator, spinal cord injury patients, dementia patients, and cerebral palsy patients.

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