Plate 52

Indications

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

Preoperative Care

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.

Anesthesia

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

Position

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.

Operative Preparation

The skin is prepared in the routine manner.

Incision and Exposure

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 antral portion of the stomach, the pylorus is delivered into the wound.

Details of Procedure

The anterosuperior surface of the pylorus is not very vascular and is the region selected for the pyloromyotomy (Figure 2). As the pylorus is held between the surgeon's thumb and index finger, a longitudinal incision 1 to 2 cm long is made (Figure 3). The incision is carried down through the serosal and muscle coats until the mucosa is exposed, but the mucosa is left intact (Figure 4). Great care must be taken at the duodenal end of the incision, for here the pyloric muscle ends abruptly, in contrast with the gastric end, and the mucosa of the duodenum may be perforated (see danger point) (Figure 1). The cut muscle is now spread apart with a straight or a half-length hemostat until the mucosa pouts up to the level of the cut serosa (Figures 4 and 5). Usually, hemorrhage can be controlled by applying a sponge wet with saline, and only rarely is a ligature or stitch necessary to control a bleeding vessel. The surgeon must ascertain that no perforation of the mucous membrane exists.

Closure

The peritoneum and transversalis fascia are closed with a running suture of 0000 chromic. The remaining fascial layers are closed with fine interrupted sutures. The skin margins are approximated with running 000000 nylon sutures or subcuticular absorbable sutures reinforced with skin-adhesive strips.

Postoperative Care

Six hours following operation, the suction is discontinued and the nasogastric tube removed. At this time, 15 mL of dextrose and water is offered to the infant. Following this, the infant is offered 30 mL of an evaporated milk formula every 2 hours until the morning after operation. Thereafter, the infant is fed progressively more formula on a 3-hour schedule.

Indications

Intussusception occurs most commonly in infants from the age of a few months to 2 years. Time must be taken to correct dehydration or debility by administering parenteral fluids. A stomach tube should be passed to deflate the stomach and to reduce to a minimum the danger of aspirated vomitus. If the intussusception has been of considerable duration and there is evidence of bleeding, as in the characteristic mahogany stools in infants, blood products should be administered with the operating room alerted and hydration established satisfactory for operation. The child is taken to the x-ray department, and here hydrostatic reduction by barium enema is attempted, utilizing a pressure of no more than 3 ft. As much as 1 hour may be spent in this procedure as long as manipulation of the abdomen is avoided and the exposure to fluoroscopy limited as much as possible. If the intussusception is going to reduce, it will progressively do so. If this method fails, surgery follows immediately. If a mass lesion or cancer is suspected in an elderly patient, then a re-section should be performed rather than a manipulation.

Anesthesia

Meperidine or morphine should be added in appropriate doses in older infants and children. Endotracheal intubation on the conscious infant is the safest anesthetic technique, followed by general anesthesia.

Position

The patient is placed in a dorsal recumbent position. Feet and hands are held flat to the operating table by straps or pinned wrappings.

Operative Preparation

The skin is prepared in the routine manner.

Incision and Exposure

In most instances a transverse incision made in the right lower quadrant provides adequate exposure. The lateral third of the anterior rectus fascia and the adjacent aponeurosis of the external oblique are incised transversely. The lateral edge of the rectus muscle may then be retracted medially and the internal oblique and transversalis muscles divided in the direction of their fibers. If more exposure is required, the incision in the anterior rectus fascia may be extended, and a portion or all of the right rectus muscle may be transected (Figure 6).

Details of Procedure

The major portion of the reduction is done intra-abdominally by milking the mass back along the descending colon, trans-verse colon, and ascending colon. When reduction has proceeded thus far, the remainder can be delivered out of the abdominal cavity. The mass is pushed back along the descending colon by squeezing the colon distal to the intussusception (Figure 7). If traction is applied, it should be extremely gentle to avoid rupturing the bowel. The discolored and edematous bowel at first may not appear to be viable, but the application of warm saline solution may improve its tone and appearance. Unless the intestine is necrotic, it is better to persist in attempts at reduction than to resort to early and unnecessary resection, required in less than 5 percent of the cases. An etiologic factor, such as an inverted Meckel's diverticulum or intestinal polyp, is found in only 3 or 4 percent of childhood cases of intussusception. It is unnecessary to tack down the terminal ileum or to anchor the mesentery. Recurrences are not common, and such preventive procedures only prolong the operation. Intussusception is uncommon in adults. It may occur at any level of the small or large intestine. After the intussusception in adults has been reduced, a search should be made for the initiating cause—i.e., tumors (especially intrinsic), adhesive bands, Meckel's diverticulum, and so forth. Resection is indicated if dead bowel is encountered.

Closure

The abdomen is closed in the routine manner. The skin margins are approximated with nylon sutures or subcuticular absorbable sutures reinforced with skin-adhesive strips.

Postoperative Care

Nasogastric suction is continued until peristaltic activity is audible or until a stool is passed. Antibiotics and colloid replacement are not necessary in an uncomplicated intussusception, but again are most valuable adjuncts in the case requiring resection. About 5 mL/kg of colloid or 5% albumin solution provides an invaluable daily supportive measure for the seriously ill child who has had resection of a gangrenous intussusception. Recurrence in the adult should suggest a cause overlooked initially but probably amenable to surgical correction, such as removal of a polyp or adhesive band.