PYLOROMYOTOMY

REASON FOR VISIT:

Congenital hypertrophic pyloric stenosis

RISK ASSESSMENT

• Family history of bleeding disorders

• Unstable cardiovascular system
• Liable heat control
• History of bleeding disorders
• History of allergy to medications
• History of allergy to anesthesia

PREPARATION OF THE PATIENT

• Blood tests
• Urine tests
• Ultrasonography
• Preoperative antibiotics were administered to the Patient with
diseases of the heart valves
• Part was prepared and draped in sterile fashion
• Oral feeding was stopped for ___hrs before procedure
• Electrolyte imbalance, fluid imbalance, acid/base imbalance was
corrected by using the intravenous infusion.
• Placement of nasogastric tube – After the diagnosis, the infant
oral feeds for the infant are suspended. Although prolonged
placement of a nasogastric tube is to be avoided, sometimes 6-
12 hours is needed to prevent further vomiting.

ANESTHESIA:

General anesthesia

POSITION OF THE PATIENT

Supine position
THE PROCEDURE

Methods

1. Open surgery
2. Laparoscopic surgery

OPEN SURGERY (FREDET-RAMSTEDT OPERATION)

• A small 3 cm incision was made in the skin with a No. 15 blade

just below the right costal margin (the right rib cage) on the
anterior abdominal wall, but above the inferior edge of the liver.
• The incision extends laterally from the outer edge of the rectus
muscle.
• Dissection was done through the subcutaneous tissues with
Bovie cautery.
• The muscle layer was carefully divided by using Bovie cautery
with the omentum or transverse colon presenting into the
wound.
• Using very gentle traction on the omentum the transverse colon
if not already visualized through the wound can be presented up
into the wound.
• Gentle traction on the transverse colon will then deliver the
greater curvature of the stomach up into the wound. The
anterior wall of the stomach is grasped with a moist sponge and
gentle traction on the stomach antrum is applied - this will
deliver the pylorus into the wound.
• The avascular (without blood supply) portion of the anterior wall
of the pylorus was identified.
• The pylorus was held between the surgeons thumb and
forefinger and a 1-2 cm longitudinal incision (along the plane of
the pylorus) was made.
• The incision was taken down through the serosal and muscle
layers until the mucosa was exposed.
 • Great care must be taken not to incise the mucosa. Extra
attention must be given to the duodenal end of the incision as
the muscle layer ends abruptly.
• The incised (cut) muscle was gently spread apart with a
hemostat until the mucosa "puffs up" to the level of the cut
serosa.
• The peritoneum and fascia of the transversalis muscle was
closed with a running absorbable suture.
• The remaining fascial layers were closed with the running or
interrupted absorbable sutures.
• The skin was closed with a subcuticular absorbable suture such
as Monocryl.
• Collodian or adhesive Steri-strips are placed on the wound.

LAPAROSCOPIC SURGERY

• A small incision was made to the depth of the umbilicus into

which a tiny camera was placed.
• Carbon dioxide was pumped into the abdominal cavity to distend
the abdomen.
• Two small incisions were made under the ribs
• 3mm instruments inserted
• An instrument holds the stomach
• Thickened pylorus was immobilized by grasping the first portion
of the duodenum and the anterior wall of the stomach, and cut
the thickened pylorus.
• No tissue is removed during the procedure,
• And the lining of the stomach was not opened.
• Over time, the pyloric muscle returns to its normal size.

AFTER PROCEDURE:

• Observe pulse rate, heart rate respiratory rate and rhythm.

• Observe temperature
• Incision will be covered with small strips of tape called STERI-
STRIPS, then by a clear dressing or gauze.
 • Baby will have a nasogastric (also called an "NG") tube in
place for several hours.
• The IV will stay in place for six to eight hours to give your
baby fluids.
• After the IV was discontinued, your baby will resume feedings
• Starting first with a small amount of PEDIALYTE. If she does
not vomit the PEDIALYTE, baby will be given NUTRAMIGEN (if
she's formula-fed) or breast milk feedings in slowly increasing
amounts.

DURATION

_______minutes

POSTOPERATIVE CARE

• Take antibiotic treatment as prescribed

• Take pain medications prescribed
• Observe for in discharge from suture site
• Surgical wound dressings will be kept clean and dry
• Start feeding after _____hrs

COMPLICATIONS:

• Undetected mucosal perforation

• Bleeding
• Persistent vomiting
• Incomplete pyloromyotomy
• Infection
• Long-term diarrhea
• Malnutrition
• Vomitings
• Regurgitation
• Difficult intubation
• Delayed onset of respiration

INSTRUCTIONS
 • Feedings: The baby may return to a regular feeding schedule
upon discharge.
• The baby should be kept sitting up for 30 minutes after each
feed. This will prevent the stomach contents from coming back
up
• Incision care: The incision should be kept clean and dry.
• Leave the steri-strips (small beige strips of tape) over the
incision. They will fall off as the wound heals.
• You may sponge bathe the baby for the first 2 days (do not put
in a bathtub), then return to normal bathing.
• Activity: There are no activity restrictions following this
operation.
• It is best, however, to lift the baby by supporting his bottom and
head and not lifting under the arms.
• Lifting under the arms puts tension on the incision and may
cause pain.

FOLLOW UP

Visit after 2 weeks