Practice Makes Perfect: Progressive Improvement of Laparoscopic Pyloromyotomy Results, with Experience

Abstract

We are able to demonstrate that, with experience, one can expect progressive improvement in the outcomes following LP in infants. Our surgery duration and complications in the last 65 cases are better than most published results for OP or LP.

What's New in Pediatric Surgery

“…Several reports have demonstrated a relatively low complication rate [19,20] but also a learning curve as noted in a recent series [21]. Early on, there were some incomplete pyloromyotomies and a mucosal perforation and, in one child, a delayed duodenal perforation, but with experience, there were fewer complications.…”

A Middle Fidelity Model Is Effective in Teaching and Retaining Skill Set Needed to Perform a Laparoscopic Pyloromyotomy

“…In addition, of the total of 7 complications occurring during the cases in the study, 6 occurred Accurately simulates difficulty in holding the duodenal end of pyloric channel 0 (0%) 3 (10%) 20 (69%) 4 (14%) 2 (7%) Accurately simulates the required depth of the serosal layer cut 0 (0%) 5 (18%) 14 (50%) 9 (31%) 1 (3%) Simulates realistic difficulty in initiating spreading 0 (0%) 3 (10%) 14 (48%) 10 (35%) 2 (7%) Accurately simulates required depth of spreading 0 (0%) 2 (7%) 16 (55%) 11 (38%) 0 (0%) Is a good tool for training pyloromyotomy to beginners 0 (0%) 0 (0%) 16 (55%) 13 (45%) 0 (0%) Is a good tool for training pyloromyotomy to expert endoscopic surgeons 0 (0%) 1 (3%) 18 (62%) 9 (31%) 1 (3%) a N ¼ 29. during the first half of cases, while 1 complication occurred during the second half. 1 These studies illustrate the ability of surgeons to improve the laparoscopic technique by acquiring proper experience, and a training model that has validity, efficacy, and reliability could help to train surgeons without increased risks to patients during the learning curve. This study successfully created a low-cost middle fidelity model of LP that emphasized the three unique maneuvers required to successfully complete the procedure.…”

“…The mucosal-sparing longitudinal splitting of the pyloric muscle was first described by Ramstedt in 1912 and is widely accepted as the gold-standard treatment for this condition to this day. 1 Technologic advancements and the increasing focus on laparoscopy have led a number of commonly performed pediatric surgical procedures, including pyloromyotomy, to be approached with minimally invasive, rather than open operative, techniques. [2][3][4][5] The laparoscopic approach has real cosmetic benefits to the patient, and operative times are shorter.…”

Reply to Letters from Dr Ceccanti and Dr Fisher

“…Surgical complications have a much lower prevalence than postoperative emesis after both procedures and would have required a much larger population to conclude noninferiority or equivalence. Secondly, the rate of complications seen in the trial (14%) is much higher than the estimated prevalence of all surgical complications after a laparoscopic approach [11][12][13]. Assuming that the true complication rate after laparoscopic approach is 5%, the sample size required for a noninferiority study with a margin of 5% (to conclude that the total complication rate after circumumbilical approach is not N5% worse than laparoscopic approach) would be approximately 700 (estimated using StudySize software).…”

“…The overall complication rate after an umbilical approach in large (∼100 or more children) series ranged from 6% to 23% [6][7][8][9][10]. The estimated prevalence of all surgical complications after a laparoscopic approach reported in large volume teaching institutions was between 3.7% and 5% [11][12][13]. Inability to see a statistically significant difference in some of the studies despite a consistent pattern of increased complications is most likely caused by the lack of power.…”