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  • 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.

Expected Benefits

  • Elimination of the mechanical gastric outlet obstruction caused by a hypertrophic pylorus.

Potential Risks

  • 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 or ...

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