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INDICATIONS

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Pyloromyotomy (Fredet–Ramstedt operation) is done in infants with congenital hypertrophic pyloric stenosis.

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PREOPERATIVE CARE

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The diagnosis is established by the characteristic history of projectile vomiting and the physical finding of a pyloric mass or “olive” on abdominal examination. This may be confirmed by an upper gastrointestinal series but more frequently by ultrasound. The correction of dehydration and acid–base imbalance by adequate parenteral fluid therapy is as important as surgical skill in lowering the mortality rate. Although prolonged gastric intubation is to be avoided, 6 to 12 hours of preparation with intravenous hydration plus suction may be necessary to restore the baby to good physiologic condition. Oral feedings are discontinued as soon as the diagnosis is made, and an intravenous infusion is started in a scalp vein. Then 10 mL/kg of 5% glucose in normal saline is administered rapidly. This is followed by a solution of one part 5% dextrose in normal saline to one part 5% dextrose in water (one-half normal saline with 5% D/W) given at the rate of 150 mL/kg per 24 hours. The baby should be reevaluated every 8 hours with respect to state of hydration, weight, and evidence of edema. Ordinarily, this solution is continued for 8 to 16 hours. After adequate urinary output is established, potassium should be added to the intravenous solutions. In the baby who is moderately or severely dehydrated, it is wise to determine the serum electrolyte values before initiating replacement therapy and to check the values in 8 to 12 hours.

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ANESTHESIA

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Endotracheal intubation on the conscious infant is the safest anesthetic technique, followed by general anesthesia.

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POSITION

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A temperature-controlled blanket is placed under the infant’s back to help compensate for the loss of body heat and to arch the abdomen slightly to improve the operative exposure. To prevent heat loss through the arms and legs, they are wrapped with sheet wadding, and the intravenous site is carefully protected.

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OPERATIVE PREPARATION

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The skin is prepared in the routine manner.

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INCISION AND EXPOSURE

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The open approach is presented. Alternatively, a laparoscopic approach may be performed. It is advisable for the general surgeon to be familiar with the open approach. A gridiron incision placed below the right costal margin, but above the inferior edge of the liver, is used. The incision is 3 cm long and extends laterally from the outer edge of the rectus muscle. The omentum or the transverse colon usually presents in the wound and is easily identified. By gentle traction on the omentum, the transverse colon is delivered and, in turn, traction on the transverse colon will deliver the greater curvature of the stomach easily into the wound. The anterior wall of the stomach is held with a moistened gauze sponge and, upward traction on the ...

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