Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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Laparoscopic pyloromyotomy: The patient is placed across the operating table so that surgeon and patient are properly aligned. A 3-mm camera port is placed through the umbilicus with an open technique, and pneumoperitoneum is created to a maximum pressure of

8 mm Hg. A short (22 cm) 3-mm 30-degree telescope is introduced. Two additional 3-mm ports are placed in the upper quadrants lateral to the rectus muscles (alternatively, the 3-mm knife and grasper can be placed directly into the abdomen (Figure 33-6). Atraumatic graspers are used to grasp the duodenum and rotate the pylorus to expose the avascular plane. An endoscopic pyloromyotomy knife (some surgeons prefer arthroscopy knives) is used to incise the pyloric serosa over the avascular plane (Figure 33-7). One of the arms of the pyloric spreader is used to deepen this incision by pushing on the brittle muscle until it gives. This maneuver is performed in the middle of the incision and never close to the duodenum. The operation is complete by spreading the muscle until the mucosa prolapses and independent movement of both pyloric halves can be verified (Figure 33-8). At this time a small amount of saline is instilled over the pylorus, and the anesthesiologist is asked to insufflate the stomach with air to check for leaks. All incisions are infiltrated with 0.25% bupivacaine and closed with 6-0 subcuticular, absorbable sutures or Steri-Strips.

Monitor

Knife

Camera

Anesthesiologist

Grasper

FIGURE 33–6

FIGURE 33–7

FIGURE 33–8

3 5 2 S E C T I O N I V • TH E A B D O M E N

3. CLOSING

The incision is closed in separate layers with running 5-0 or 6-0 polyglactin sutures. Posterior rectus fascia and peritoneum are closed together; no attempt is made to close the peritoneum by itself. The rectus muscle does not need to be reapproximated. After closure of the anterior rectus fascia, interrupted subcutaneous sutures of 6-0 polyglactin will obliterate any dead space. The skin is closed with subcuticular 6-0 undyed absorbable monofilament sutures and adhesive strips. Before closing, the skin is infiltrated with 0.25% bupivacaine without epinephrine at the appropriate dose.

STEP 4: POSTOPERATIVE CARE

Maintenance intravenous fluids are continued until the patient is tolerating bottle feeds, which are started 4 to 6 hours after the operation and gradually advanced. It is a good practice to examine the patient’s abdomen before proceeding with enteral feeds. Many surgeons use an electrolyte solution such as Pedialyte for the first feed. Some vomiting can be expected. Most patients are ready for discharge 24 to 48 hours after the procedure.

Complications: The most dreaded complication of this procedure is duodenal perforation, which is reported in approximately 1% of open pyloromyotomies and between 1% and 2% of laparoscopic pyloromyotomies. Every effort must be made to identify this complication at operation, so that the entire pyloromyotomy can be closed with interrupted 4-0 silk sutures and a new pyloromyotomy performed. The patient is kept on intravenous fluids, antibiotics, and orogastric suction for 2 to 3 days. A contrast study to confirm patency of the pylorus and absence of leaks is performed before resuming enteral feeds. Failure to recognize a perforation results in life-threatening peritonitis and sepsis that mandates immediate resuscitation, and administration of broad-spectrum intravenous antibiotics, followed by laparotomy and washing of the abdominal cavity. The original pyloromyotomy is closed as described previously, and a new pyloromyotomy is performed.

Postoperative care is done in a critical care setting, and the need for hemodynamic support is not unusual. These young patients have an increased incidence of wound infections and wound dehiscence.

Up to one third of infants after an uncomplicated pyloromyotomy will experience vomiting, which is typically self-limited. Vomiting is usually managed by holding the next feed and resuming feeds 6 hours later. If vomiting persists, one must begin to consider the possibility of an incomplete pyloromyotomy. Although vomiting is not unusual after pyloromyotomy, abdominal distention is. Abdominal distention should prompt the surgeon to stop feeds and investigate for duodenal leaks. Wound infections after uncomplicated pyloromyotomy occur in approximately 2% of cases, and wound dehiscences are quite rare.

STEP 5: PEARLS AND PITFALLS

Avoid incisions that extend into the duodenum. This will surely result in perforation, because the area of the distal pylorus and proximal duodenum is extremely thin. In fact, the scoring incision made over the pylorus should stop 2 to 3 mm short of the ring that is palpated at the distal pylorus. Spreading wide proximal to this area will result in disruption of the hypertrophic muscle fibers and release of the constrictive ring.

SELECTED REFERENCES

1. Lobe T, Kumar T: Pyloromyotomy. In Spitz L, Coran AG (eds): Operative Pediatric Surgery, 6th ed. London, Hodder Arnold, 2006, pp 367-375.

2. Ashcraft K: Atlas of Pediatric Surgery. Philadelphia, Saunders, 1994, pp 85-89.

3. Fujimoto T: Pyloromyotomy. In Najmaldin A, Rothenberg S, Crabbe D, Beasley S (eds): Operative Endoscopy and Endoscopic Surgery in Infants and Children. New York, Oxford University Press, 2005, pp 231-234.

C H A P T E R 34

ROUX-EN-Y GASTRIC BYPASS

(OPEN AND LAPAROSCOPIC)

Michael D. Trahan

STEP 1: SURGICAL ANATOMY

Experience with the anatomy and surgical procedures of the esophagogastric junction are a prerequisite to a successful gastric bypass operation (Figure 34-1).

STEP 2: PREOPERATIVE CONSIDERATIONS

The standard indications for a bariatric operation include either a body mass index of at least 40 kg/m2 or a body mass index of at least 35 kg/m2 with significant associated medical illness. Potential patients must also have tried multiple dietary, activity, and lifestyle modification programs. They should be free of substance abuse and psychologically stable so that they can make an intelligent decision regarding the risks of the operation and the need to dramatically alter their lifestyles.

Bariatric operations should not be offered unless a dedicated team is in place for the thorough preoperative evaluation and close long-term follow-up that are required for every patient.

Patients should receive prophylaxis against wound infection with an intravenous cephalosporin and against venous thrombosis with sequential compression devices and low- molecular-weight heparin before induction of anesthesia.

General anesthesia is required for this operation. An anesthesia team specially trained and equipped for the morbidly obese patient is necessary.

Obtaining a controlled airway can sometimes be quite challenging in the morbidly obese patient. A fiber-optic scope can be very helpful for an awake intubation. Elective tracheostomy is sometimes a good idea for the massively obese patient, especially one who already has some baseline respiratory dysfunction where airway control may continue to be a problem postoperatively.

Each incision site is preemptively anesthetized with local anesthetic injection.

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