Non-laparoscopic minimal surgical approach to pyloromyotomy: An experience from a challenged resource setting

Abstract

Background:The aim of the study is to review the experience with the classic Ramstedt's pyloromyotomy through the RUQ approach and the circumlinear supraumbilical fold approach (circumumbilical [CU]) pyloromyotomy (an approach that combines the ease and safety of the open pyloromyotomy with the advantages of minimal invasiveness).Patients and Methods:A single centre review in a period of 12 years from January 2001 to December 2013 with the institutional ethical committee's approval, evaluating 316 pyloromyotomies based on surgical approach: RUQ (171); and CU (145). Patients’ demographics, acid-base/electrolyte status on presentation, mean operative time (MOT), postoperative length of stay (LOS) at hospital, and complications were recorded.Results:Patients demographics, acid − base/electrolyte status on presentation; and MOT were not significantly different. The median LOS was 33 and 30 minutes for CU and RUQ, respectively, with no statistical significant difference between the two groups. One patient in the CU group had a late adhesive bowel obstruction requiring laparotomy and bowel resection. Moreover, wound infection rates did not differ significantly between the two groups (CU 3; and RUQ; 3; P = 0.15).Conclusions:Pyloromyotomy is associated with a low complication rate. Cosmetically, CU is superior to the RUQ approach. Its short learning curve and the feasibility to examine the integrity of the duodenal mucosa intraoperatively may make CU a safer alternative in case of surgeons who are still practicing the RUQ approach in countries with a challenged resource settings.

Minimally Invasive Supraumbilical Approach for Pyloromyotomy

“…Supraumbilical approach for pyloromyotomy is reported to be accessible to perform with less need of equipment and by less experienced pediatric surgeons or residents, which our experience confirms. 10,24 One of the SUI pyloromyotomies was performed by a resident in Pediatric Surgery with two years of experience and other two by a pediatric surgeon with eight years of experience. Accordingly, Robertson incision was also performed by the same surgeons.…”

“…and certain authors apply it also in operating other anomalies -malrotation, duodenal atresia, and intestinal atresia. 7,8,[10][11][12][13]18,20,24,25 There are several recent studies comparing the three surgical modalities in terms of feasibility, complication rate and scar quality. Despite presenting controversial results, they show that the laparoscopic and supraumbilical approaches are slightly superior to the Robertson approach.…”

“…The SUI seemed to be safer and even more efficient than the laparoscopic method, with lower complication rate, shorter hospital stay and an almost invisible scar left. 4,7,8,12,14,22,24 It is also easier to be performed in less technologically-advanced centres and by surgeons with less experience with this technique and by resident stuff, in contrast with the experience needed for a safe laparoscopic pyloromyotomy. 10,24 In pediatric surgery centres in Bulgaria pyloromyotomy is performed via Robertson incision or laparoscopically and SUI has never been used until this case series.…”

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“…Zakaria reported that the rate of infection was 2% (3 infections/145 surgeries) among patients having circumumbilical pyloromyotomy approach and 1.8% (3 infections/171 patients) among patients having the classic Ramstedt's pyloromyotomy approach. [20] SSIs in Al-Qassim…”