- Projectile nonbilious emesis in an infant.
- Palpable "olive" on physical examination.
- "String sign" on an upper gastrointestinal series.
- Pyloric muscle wall thickness ≥ 4 mm and pyloric channel length ≥ 16 mm on ultrasound examination.
- Severe hypochloremic, hypokalemic metabolic alkalosis.
- Severe dehydration.
- The procedure is successful in nearly 100% of cases.
- Elimination of the mechanical gastric outlet obstruction caused by a hypertrophic pylorus.
- Incomplete myotomy (usually gastric).
- Mucosal perforation (usually duodenal).
- Wound infection.
- Postoperative bleeding.
- Fascial dehiscence.
- Open pyloromyotomy: pyloric spreader (Benson).
- Laparoscopic pyloromyotomy.
- Veress needle and sheath.
- 5-mm umbilical port.
- 3-mm instruments, including laparoscopic pyloric spreader.
- Pyloric stenosis is not a surgical emergency; the goal of preoperative evaluation is to confirm the diagnosis and to correct metabolic derangements caused by persistent vomiting.
- Diagnosis is based on a thorough history and physical examination and is usually confirmed by radiographic findings.
- A history of projectile nonbilious vomiting between ages 4 and 6 weeks and a palpable "olive" is sufficient for diagnosis.
- If the diagnosis is unclear, ultrasound examination of the pylorus is the radiologic procedure of choice.
- Criteria for ultrasound diagnosis are pyloric muscle wall thickness ≥ 4 mm and pyloric channel length ≥ 16 mm.
- Once the diagnosis is suspected, the patient should not ingest anything orally.
- Preoperative nasogastric decompression is not required and may exacerbate the metabolic alkalosis.
- The most common metabolic abnormality is hypochloremic, hypokalemic metabolic alkalosis (HCO3 ≥ 30 mEq/L) and overall volume deficit.
- The patient should be rehydrated with 20 mL/kg boluses of normal saline until urinating and then given D5½ normal saline (10–20 mEq KCl/L if indicated) at a maintenance rate of 1.5. Lactated Ringer solution is contraindicated because it may exacerbate the metabolic alkalosis.
- Figure 46–1A: For both open and laparoscopic procedures, the infant should be supine on the operating table.
- Laparoscopic procedure.
- The infant is positioned supine at the end of the operating table with appropriate padding.
- The lower extremities are secured to the operating table in a frog leg position.
- Before induction of anesthesia, nasogastric decompression should be performed.
- Figure 46–1B: A longitudinal incision is made in the umbilicus and a Veress needle and trocar sheath are inserted.
- A CO2 pneumoperitoneum is established to a level of 10–12 mm Hg, and a 5-mm port is inserted.
- Under direct vision, a No. 11 blade is used to make two 3-mm stab incisions in the upper abdominal wall.
- Figure 46–1C: An open pyloromyotomy is performed using a right upper quadrant or umbilical skin incision.
- Right upper quadrant incision: a transverse incision is made directly over the right rectus muscle midway between the xiphoid and umbilicus. The rectus muscle may be divided transversely ...
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