What Is Pyloromyotomy?

Pyloric myotomy was the first surgical method proposed by Dufou and Fredet in 1907 to cut the pyloric muscle to the submucosa and the adjacent medial oblique muscle to achieve the purpose of treating congenital hypertrophic pyloric stonosis. . In 1912, Rammstedt simplified the procedure by not suture the fissures of the pyloric muscle. This technique is recognized by the world as the preferred technique with its positive and satisfactory effects, and it is still in use today.

Pyloric myotomy

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Pyloric myotomy was the first surgical method proposed by Dufou and Fredet in 1907 to cut the pyloric muscle to the submucosa and the adjacent medial oblique muscle to achieve the purpose of treating congenital hypertrophic pyloric stonosis. . In 1912, Rammstedt simplified the procedure by not suture the fissures of the pyloric muscle. This technique is recognized by the world as the preferred technique with its positive and satisfactory effects, and it is still in use today.

Pyloric myotomy

Pyloromyotomy; pyloromyotomy; Wei-La surgery; extramucosal pyloromyotomy

Pediatric Surgery / Stomach Surgery

43.3 01

Pyloric myotomy was the first surgical method proposed by Dufou and Fredet in 1907 to cut the pyloric muscle to the submucosa and the adjacent medial oblique muscle to achieve the purpose of treating congenital hypertrophic pyloric stonosis. . In 1912, Rammstedt simplified the procedure by not suture the fissures of the pyloric muscle. This technique is recognized by the world as the preferred technique with its positive and satisfactory effects, and it is still in use today.

Pyloric myotomy is suitable for hypertrophic pyloric stenosis. After diagnosis, except for those with atypical symptoms and mild illness, non-surgical treatment can be taken first, and they should be treated as soon as possible after appropriate pre-operative preparations.

Sick children often suffer from chronic dehydration or alkalosis due to frequent vomiting, with varying degrees of malnutrition. Active preoperative preparations must be done for 1 to 2 days to improve their overall condition to facilitate surgical safety.

1. According to the clinical manifestations of the sick child and the results of blood biochemical examination, intravenous fluid replacement is given to correct the water, electrolyte, acid-base imbalance, and appropriate calcium supplementation if convulsions. Transfusion of plasma or whole blood if necessary.

2. Because most children have pyloric insufficiency obstruction, feeding should be stopped, but it is not necessary to place a gastric tube to continue decompression. Severe obstruction symptoms, gastric lavage with warm saline the night before surgery to reduce gastric mucosal edema. It is not necessary to keep the gastric tube, and then place the gastric tube in the morning.

3. Actively treat existing coexisting diseases such as pneumonia.

Basic anesthesia plus local infiltration anesthesia or epidural anesthesia can be used, and tracheal intubation can be used for general anesthesia when necessary. The sick child is placed in the supine position. In order to increase the exposure of the right inferior incision, the right lower chest and back can be slightly cushioned, and the sick child's head is turned to the left.

1. The scope of the incision surgery is small. The incision must be adequately exposed, and the effects of reducing abdominal wall trauma, avoiding dehiscence, and aesthetic appearance must also be considered. The incision is close to the costal arch, and the liver under it protects the incision. Avoid cutting the muscle as much as possible to facilitate healing. At present, Robertson advocates the right subcostal lattice incision, that is, the oblique incision 1.5 to 2.0 cm parallel to the right costal margin. The inner end of the incision is the outer edge of the right rectus abdominis, and the abdominal wall muscle layer is layer by layer according to its fiber direction The method of separation is similar to that of an appendix surgical incision. If the incision is inadequate, cut the outer edge of the rectus sheath slightly. In addition, the upper right side or the right rectus abdominis incision is acceptable. Make a transverse incision into the abdominal cavity.

2. After opening the abdominal cavity, gently pull the lower edge of the liver upward. The surgeon uses his right finger and thumb to probe the enlarged pyloric mass and lift it out of the incision. The surgeon changed the left thumb and finger to fix the mass.

3. In the anterior wall of the pyloric mass, there is no blood vessel area, and the serosal layer is cut longitudinally. The gastric side of this incision can reach the edge of the mass, and the duodenal end must stop near the edge of the mass, and do not exceed. Because the pylori hypertrophic ring muscle protrudes into the duodenal cavity, the duodenal mucosa overlaps and covers the distal surface of the mass. The mucosa here is very close to the aforementioned serous membrane incision, which is a dangerous area for surgery. If you accidentally cut the duodenum.

4. After serous membrane incision is performed for pyloric muscle incision, the superficial muscle fibers can be carefully cut with a knife, then the muscular layer is bluntly separated with a small knife handle, followed by dedicated pyloric separation forceps for separation, each operation must be Under direct vision, such as mosquito hemostatic forceps, do not insert the tip of the forceps into the tissue to separate them blindly. The pyloric mucosa naturally bulges into the muscle fissure after the muscle is broken. When separating the two ends of the mass, care should be taken to protect the mucosa until the pyloric mucosa bulges. When there is a small bleeding point on the muscle section, you can use warm saline gauze to compress the bleeding. Or use a small needle 1-0 silk suture to stop bleeding, should not penetrate the stomach cavity, can also use a needle electric knife electrocoagulation to stop bleeding, but should be careful to avoid damage to the mucosa.

5. After the pyloric muscle incision is completed, squeeze the gas in the stomach into the duodenum, check whether it passes smoothly, and pay attention to the mucous membrane for damage and leakage. If it is found that the mucosa is damaged, it is often difficult and dangerous to simply repair it. Generally, the mucosal hole is repaired with absorbable sutures. The other part of the duodenum is used to re-disconnect the pyloric muscle to form the deltoid muscle flap. The perforated side muscle layer and the triangular muscle flap were sutured intermittently to repair the damage, and satisfactory results were still obtained. Check the mucosa for no leakage and hemostasis, and then return the pylorus to the abdominal cavity. In general, abdominal drainage is not placed. If the duodenal mucosa is damaged and the repair is not satisfactory, abdominal drainage can be placed.

1. If the operation goes well, the gastric tube may not be left after the operation. 8 to 12 hours after surgery, first give 5% glucose solution, 10 to 20 ml each time; once every 1 to 2 hours; after feeding 2 to 3 times, if there is no vomiting, give the same amount of milk or breast milk, and gradually increase the amount, the full amount Artificial feeding was started more than 24-48 hours after surgery.

2. Patients with pyloric mucosa damage during operation, sustained gastrointestinal decompression for 48 to 72 hours. Then feed water and milk according to the method above.

3. Patients who cannot feed normally on time after operation should promptly receive intravenous fluids and nutritional support.

4. Pay attention to whether there is poor performance of pylorus passage or intra-abdominal infection.

1. A small number of sick children still have vomiting after surgery, which usually relieves after 24 hours, and some of them continue for more than 2 to 3 days. If continuous vomiting, the reasons may be: incomplete incision of the pyloric muscle; edema of the pyloric mucosa; postoperative gastric dilation; coexisting gastroesophageal reflux. If vomiting persists for more than 4 weeks, a barium meal should be performed to determine the cause of vomiting, and reoperation should be performed with caution.

2. Due to malnutrition in most sick children, complications of abdominal wall incisions are more likely to occur, such as dehiscence of abdominal wall incisions, incisional hernias, and incision infections. Therefore, the suture technique of each layer of the abdominal wall should be paid attention to during surgery to enhance nutritional support after surgery.