Pyloromyotomy

Codes

Laparoscopic Pyloromyotomy CPT 43520

Background

Traditionally an open surgery, this procedure is almost universally done laparoscopically now. In the past, patients were kept NPO for long peroids of time afterwards, now we feed them and advance diet relatively quickly.

Indications

Pyloric stenosis (K31.1)

Preoperative workup

Patients present with metabolic alkalosis with associated hypochloremia and hypokalemia.

This must be corrected prior to going to the operating room.

Normal saline bolus with the protocol found in the pediatrick Dr. Ham handbook, and then start 1.5 MIVF.

Cl goal >97.

Bicarb goal <30.

Surgical technique

The patient is positioned with a screen above the the head of the patient.

If the baby is small enough, can position the patient sideways on the table to allow better position for the surgeon to work.

Prep and drape like normal.

Enter the abdomen through a vertical umbilical incision.

In young patients, the umbilical vein may be patent care must be taken not to introduce the port into this insufflate air into the venous system.

Working ports through stab incisions in the RUQ and LUQ.

Grasp the distal pylorus with the left hand.

Introduce flat tip Bovie in the right stab incision and create a longitudinal incision over the area of most hypertrophy.

Gently spread with graspers until a bulging submucosa is visualized.

Spread proximally and distally in this area until the thickest areas of muscle are separated.

Care must be taken at the distal spreading as injuries the duodenum can be devastating.

The submucosa should be bulging, and each lip of the split muscle layer should move independently of each other.

Some do a leak test.

Close incisions and umbilical fascia as normal.

Complications and post-op care

Use Dr. Ham post op pyrlous orderset in his shared “My plan favorites”.

Follow the standard advancement protocol.

• NPO for 4 hrs
• Discontinue any GERD medicines (do not resume on discharge)
• Then start with 1 oz and advance by 1 oz per feed until goal (EBM or formula)
  • D/C home after tolerating 3 consecutive successful feeds
  • If emesis occurs, wait 3 hours then attempt feeds again at previous volume

NO NGT OR OGT TUBE SHOULD BE PLACED.

The younger and more severe the case, the more up and down the post op feeding will be.

Must counsol the family and nursing staff that some emesis is normal.

Surgeon specifics

Sample dictation

laparoscopic pyloromyotomy 43520

After informed consent was confirmed, the patient was taken to the operating room and placed in the supine position. The patient was intubated by anesthesia. The patient was prepped and draped in the usual sterile fashion. A timeout was performed.

Vertical umbilical incision was made, and a 5 mm Veress needle and sheath were introduced into the abdomen. 5 mm step port inserted. Laparoscope confirmed intra-abdominal entry. Insufflation to 8 mm Hg. Scope confirmed no bowel injury. 2 additional incisions were made in RUQ and LUQ. The pylorus was identified. A longitudinal incision was made with cut cautery across the pylorus from the pyloro-duodenal junction to the pyloro-gastric junction. The muscle fibers were bluntly dissected, avoiding any mucosal injury. There was minimal bleeding. The pyloric walls were moveable independently. The umbilical facial defect was closed with 3-0 Vicryl single stitch. The facial layer of the LUQ incision was closed with single 5-0 Monocryl stitch. Then skin was closed with 5-0 Monocryl. LUQ and RUQ incisions dressed with Dermabond. 2x2 and Tegaderm applied to umbilical port site.

The patient was awakened without issue and transported back to the IMCU in stable condition.

Dr. Harmon was present for and supervised the entire operation.