A Novel Nonelectrosurgical Technique for Incising the Pylorus in Laparoscopic Pyloromyotomy

Introduction

Laparoscopic pyloromyotomy was first described by Alain in 1991. ¹ Many techniques have been described for incising the serosa of the pylorus^1–5 ; however, after the introduction of the arthrotomy knife for cutting the serosa, it gained near universal acceptance as the gold standard. Unfortunately it was removed from the market and is no longer available.

Since the removal of the arthrotomy knife from the market, pediatric surgeons worldwide have innovated to find an acceptable alternative. Some have found success and advocated using cautery—either a long protected flat bovie tip ⁵ or hook cautery ⁴ —whereas others have searched for a replacement for the cold knife technique, ² citing concerns about electrosurgical energy. These concerns over transmission of electrosurgical energy prompted the innovation of a new method for incising the pyloric serosa that is not subject to market pressures as in the case of the arthrotomy knife. We describe this novel technique herein.

Methods

After institutional ethics review was obtained, a retrospective chart review was performed between January 2012 and September 2015 of a single surgeon's experience with laparoscopic pyloromyotomy at King Abdullah University Hospital in Irbid, Jordan. Patient demographics and outcomes were recorded.

An 18 gauge needle with attached syringe was inserted percutaneously just above the hypertrophied pylorus; after stabilizing the pylorus with a grasper through the right upper quadrant port, the needle was introduced to gently incise the serosa then reincising across the muscle fibers from duodenum to stomach, cutting the hypertrophied edematous muscle fibers. It is very easy to feel the serrations of the muscle with the feedback provided by the needle. The muscle is then spread to the level of the mucosa as with other previously described techniques of laparoscopic pyloromyotomy.

Results

Six patients (3 boys and 3 girls) underwent laparoscopic pyloromyotomy using the novel technique already described between January 2013 and September 2015. Table 1 shows the demographics of the patients undergoing laparoscopic pyloromyotomy with percutaneous needle incision of the pylorus.

Of these patients, none was converted to open. There were no intra- or postoperative complications in this series including perforations or patients with hemorrhage, and no delays to start feeding.

Discussion

Although cutting the pylorus with cautery has been shown to be safe and effective,^4,5 there are still surgeons who are uncomfortable enough using cautery on the pylorus that it prevents them from performing laparoscopic pyloromyotomy. Others are “nervous users” of the cautery. Given the recent industry interest in development of new cutting devices, it seems that pediatric surgeons are still searching for a viable alternative to the arthrotomy knife.

Although this technique is not flashy, it satisfies a need with equipment that is readily available in every operating room in the world. There is no need to raid other specialties' supply closets or search for the holy grail of specialty knives. In addition, it is very inexpensive—something severely lacking in modern medicine.

This technique is not meant to supplant electrosurgical options for those who are happy with them but rather to serve as another option in the tool belts of minimally invasive surgeons for children. It may woo some surgeons toward laparoscopic pyloromyotomy who previously used the arthrotomy knife and have since abandoned the technique in favor of open surgery. In addition, it may serve as an option for those “nervous users” of the cautery who have not taken the time to search out other nonelectrosurgical options.