Laparoscopic pyloromyotomy: Lessons learnt in our first 101 cases

Abstract

Aim:To analyze our experience with laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis for the lessons that we learnt and to study the effect of learning curve.Materials and Methods:This is a retrospective analysis of case records of 101 infants who underwent laparoscopic pyloromyotomy over 6 years. The demographic characteristics, conversion rate, operative time, complications, time to first feed and post-operative hospital stay were noted. The above parameters were compared between our early cases (2007-2009) (n = 43) and the later cases (2010-2013) (n = 58).Results:89 male and 12 female babies ranging in age from 12 days to 4 months (mean: 43.4 days) were operated upon during this period. The babies ranged in weight from 1.8 to 4.7 kg (mean: 3.1 kg). Four cases were converted to open (3.9%): three due to mucosal perforations and one due to technical problem. The mean operative time was 45.7 minutes (49.7 minutes in the first 3 years and 43.0 minutes in the next 3 years). There were 10 complications-4 mucosal perforations, 5 inadequate pyloromyotomies and 1 omental prolapse through a port site. All the complications were effectively handled with minimum morbidity. In the first 3 years of our experience the conversion rate was 9.3%, mucosal perforations were 6.9% and re-do rate was 2.3% as compared to 0%, 1.7% and 6.9%, respectively, in the next 3 years. Mean time for starting feeds was 21.4 hours and mean post-operative hospital stay was 2.4 days.Conclusion:Laparoscopic pyloromyotomy is a safe procedure with minimal morbidity and reasonable operative times. Conversion rates and operative times decrease as experience increases. Our rate of inadequate pyloromyotomy was rather high which we hope to decrease with further experience.

Minimally Invasive Pediatric Surgery: The Learning Curve

“…Binet et al 25 noted a significant decrease in operative time and complication rates over time with an estimation of 10 cases needed to master the operative technique and best results obtained after 20 procedures. Handu et al 26 reported a decrease in operative time, conversion, and mucosal perforations (6.9% in the learning period compared with 1.7% in the late period); however, they also observed an inexplicably increased redo rate in their late period. Oomen et al 27 found significantly less complications (e.g., wound infection and delayed passage) in their late period as compared with the early period group, setting the learning curve at 35 cases.…”

Laparoscopic Pyloromyotomy: A Study of the Learning Curve

“…20 Our overall conversion rate of 3.7% was comparable to those reported by other authors. [20][21][22] These conversions were due to mucosal perforations in all cases. In our experience, the conversion rate does not decrease with growing experience.…”

“…28 Time before full feed and postoperative hospital length of stay have been studied as markers of postoperative recovery by many authors. 22 There is no consequence of the improvement of the mean operative time for the ad libitum feeding time. The utilization of the postoperative feeding procedure explains totally these last results.…”

“…In our experience, the conversion rate does not decrease with growing experience. Some articles reported a significant decrease of the mucosal perforation rate according to experience, from 6.9 to 1.7% 22 or from 8.3 to 0.7%. 15 Our rate is less than others at the beginning of experience but stabilizes across the learning curve, according to the three stages (3.7%).…”

Minimally Invasive Supraumbilical Approach for Pyloromyotomy

“…In children approached with Robertson incision these rates are 1.4%; 0.3% and 2.5%, respectively. 2,[6][7][8][9][10]15,19,21 Besson 3 reports converting to Robertson incision due to inadequacy of the performed SUI in 3.1%. All five children in our study were operated via SUI without the need of additional incision.…”