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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 3  |  Issue : 2  |  Page : 22-26

Extended Umbilical Incision for Pyloromyotomy: Our Experience


1 Assistant Professor, Department of Paediatric Surgery, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar, India
2 Professor, Department of Paediatric Surgery, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar, India
3 Additional Professor, Department of Paediatric Surgery, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar, India
4 Senior Resident, Department of Paediatric Surgery, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna-14, Bihar, India

Date of Web Publication11-Dec-2020

Correspondence Address:
Ramdhani Yadav
Assistant Professor, Department of Paediatric Surgery, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna -14, Bihar
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Background: Classical incision for open Pyloromyotomy in patients of Infantile hypertrophic pyloric stenosis (IHPS) leaves a prominent scar. By providing better cosmesis without affecting the accessibility to the pathologic site, incision hidden in the umbilical scar would serve as an alternative to the classical incision.
Objective: To compare the results of Extended umbilical incision with that of classical incision for Pyloromyotomy in patients of IHPS.
Methods: Intra-operative and post-operative details of 20 patients of IHPS who underwent pyloromyotomy through extended umbilical incision were compared to 20 other patients where Right upper transverse incision (classical incision) was used in the Department of Paediatric surgery, at a tertiary care centre.
Results: No statistically significant differences were observed between the two groups in intra-operative time, complications and post-operative stay in hospital. Umbilical incision had better cosmesis.
Conclusion: Although right upper transverse incision has been generally advocated in neonates and infants, we found that a less conspicuous wound in the garb of the umbilical scar is more cosmetic and convenient, within the current principles of minimally invasive surgery. It combines the ease and safety of open pyloromyotomy with the advantages of minimal invasiveness.

Keywords: hypertrophic pyloric stenosis, pyloromyotomy; umbilical incision


How to cite this article:
Yadav R, Rahul SK, Kumar V, Thakur VK, Hasan Z, Agarwal A. Extended Umbilical Incision for Pyloromyotomy: Our Experience. J Indira Gandhi Inst Med Sci 2017;3:22-6

How to cite this URL:
Yadav R, Rahul SK, Kumar V, Thakur VK, Hasan Z, Agarwal A. Extended Umbilical Incision for Pyloromyotomy: Our Experience. J Indira Gandhi Inst Med Sci [serial online] 2017 [cited 2021 Dec 7];3:22-6. Available from: http://www.jigims.co.in/text.asp?2017/3/2/22/303141




  Introduction Top


Classical incision (CI) described for Ramstedt’s Pyloromyotomy is Upper Right supra-umbilical transverse incision. This incision leaves a conspicuous scar. We have recently used umbilical incision (UI) with a slight extension to the right side if needed to approach the pathological site in these patients. The relatively large and distended stomach eases the delivery of the olive through this incision and therefore a cosmetically superior scar hidden in the umbilicus results which makes this incision a suitable alternative to the CI.


  Material and Methods Top


Study design

This was a retrospective comparative study. Data regarding the personal details, clinical features, intra-operative and post-operative details of patients of IHPS who underwent pyloromyotomy through extended UI and Right upper transverse incision (CI) in the Department of Paediatric surgery, Indira Gandhi Institute of Medical Sciences, Patna from January, 2015 to December 2016 were collected. These patients formed the study and control groups respectively. Initial steps, common to both groups

Patients presenting with a classical history of repeated non- bilious projectile vomiting were resuscitated with fluids and a naso-gastric (NG) tube was inserted to lessen chances of aspiration and institute chilled saline wash. Adequate hydration and electrolyte corrections were done as per the blood gas analyses and serum electrolyte report. After appropriate corrections in blood gas and serum electrolytes and evaluation with a sonogram, patients were taken up for surgery.


  Pyloromyotomy via Classical Incision (CI) Top


Upper Right supra-umbilical transverse incision was taken over the skin and the abdominal wall muscles were divided to approach the hypertrophied pylorus. Omentum was brought down and towards left to facilitate the delivery of the olive into the surgical wound. Pyloromyotomy was done starting from the beginning of the hypertrophied pylorus and ending short of the vein of Mayo (2-3mm proximal to the distal-most level of the hypertrophied pylorus). Gentle spreading of the muscles was done till mucosa was visible. Surgical wound was then closed in layers using interrupted sutures.


  Pyloromyotomy via Umbilical/Extended Umbilical Incision (UI) Top


Initial incision was taken along the superior margin of the umbilical scar. Muscles were divided on either side of the midline. Distended stomach in IHPS is at a relatively lower position and this helps it to be approached through the UI. Babcock’s forceps was used to bring the olive in the surgical field. If the size of the olive was large, difficulty in delivering it would have led to serosal tears. So, in such cases, slight extension of the umbilical incision to the right side was done to facilitate the delivery of the hypertrophied pylorus into the surgical field [Figure 1] & [Figure 2]. Rest of the steps were same as for pyloromyotomy via CI.
Figure 1: Extended umbilical incision for IHPS

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Figure 2: Extended umbilical incision (post-surgery)

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Post-surgical management common to both groups Patients were kept on free NG tube drainage on the day of surgery and the nature and amount of its aspirates were noted. If amount was less and clear, they were started on NG feeds and on tolerating it, they were breast fed with adequate burping. In case the NG output was significant in amount or altered coloured, NG tube was kept for a longer duration and if needed, chilled saline wash was given to reduce post-operative oedema. Feeds were started when the output through the NG tube lessened. In cases, with complications like breech of mucosa during surgery, NG tube was kept for at least three days. For Post-operative analgesia, intravenous Paracetamol was given in dosage of 15mg/kg body wt., 8 hourly. Tachycardia and inconsolable cry were taken as signs of additional analgesic requirement. Patients were discharged once they tolerated breast feeds adequately.


  Variables Studied and Statistical Methods Top


Age at presentation, duration of symptoms, sex, patient’s weight, acid-base status, chloride level, Ultrasound findings, type of incision used for surgery, duration of surgery , any intra-operative or post-operative complications and post-operative duration of stay were the variables studied. Any technical difficulties encountered during the procedure and complications in the postoperative period were noted. Results obtained in the two groups were tabulated and analysed.

Data were presented as mean and standard deviation, where appropriate. Chi - square test and Fischer’s exact test were used for categorical data. For statistical significance, a P-value <0.05 was considered to be significant.

If parameters like intra-operative difficulty in delivering the olive, dimension of the surgical wound, intra-operative time and difficulty in dealing with complications and postoperative length of hospital stay would not be significant, it would establish extended UI as a better alternative to the CI. Patients with intra-operative complications were excluded from analyses of intraoperative time and post-operative length of stay.


  Results Top


  1. Demographic variables - The two groups did not vary significantly in age at presentation, sex ratio, body weight, duration of symptoms. [Table 1] summarizes the values of these variables in the 40 patients included in the study.
  2. Olive palpable clinically in 40% cases.
  3. Mean intra-operative length of olive - 24.6mm.
  4. Ultrasonogram findings - [Table 2] summarizes the sonogram findings in these 40 patients
  5. Umbilical incision versus Classical incision - [Table 3] gives a summary of the observation made in the two groups
Table 1

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Table 2

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Table 3

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  Discussion Top


As early as 1986, Tan and Bianchi et al. described the umbilical incision for performing pyloromyotomy[1]. Although several modifications of this incision have been described in literature including the circum-umbilical incision, omega-shaped incision, Mercedes Benz incision and umbilical incision extending to the right side when needed, classical upper transverse right supra-umbilical incision is still being used in many centres[2],[3],[4],[5],[6],[7],[8].

Several investigators have reported the versatility of UI in infants[3],[9]. It has been used in approaching a wide variety of pathologies involving the umbilicus, lesions in the vicinity of the umbilicus including urachal and vitello- intestinal anomalies and small bowel pathologies. It remains the most important port site during laparoscopic surgery and has often been used as a stoma site in paediatric patients. Incision in this region provides quick access to the peritoneal cavity due to less musculature in the midline and less bleeding due to absence of any major crossing vessel in the midline. It can be extended in any direction with ease depending on the need during the surgical procedure. Scars in this region are cosmetically superior as they can be hidden in the garb of the original umbilical incision.

In this study, we aimed to compare IHPS patients undergoing surgery via CI and UI. These two groups did not vary in mean age at presentation, duration of symptoms, body weight, sex ratio and maturity at birth.

Mean age of presentation to the hospital was 39days in the 40 patients constituting both groups and they had been symptomatic for a mean of 12 days with repeated non- bilious vomiting as the most common presenting symptom. They had a mean body weight of 2.4kg. As reported elsewhere in literature, predominantly males had IHPS in this study compared to females.

Some of these patients presented late with dehydration and electrolyte imbalance. They needed fluid and electrolyte replenishment before being fit for surgery. In a few patients, it took as long as 48 hours for fluid and electrolyte imbalances to get corrected. Mean pH was 7.42 and mean chloride level was 101.5 at presentation.

Classical olive was palpable in only 40% patients and so diagnosis was made mostly considering the symptom of repeated non-bilious projectile vomiting in an infant after 2 weeks of birth and sonographic findings at presentation. Sonographic evidence of IHPS includes a long and thick pylorus with increased vascularity on Doppler in its wall[10],[11]. In our study, the mean pyloric length was 19.4mm and mean pyloric thickness was 4.8mm on sonogram. Increased vascularity of the pyloric muscle and mucosa was evident in as many as 82% of cases. Increased pyloric muscular and mucosal vascularity has been recently emphasised upon by several investigators[11]. All these sonographic parameters are variable according to patient’s age, technique, radiologist’s experience and patient’s calmness[11]. Macdessi and Oates et al. had reported a fall in the clinical detection of the olive in the post - sonogram era from 87% to 49%[12]. Our study also reflects this phenomenon and we increasingly depend on sonogram for a definite diagnosis and to rule out other conditions like pylorospasm. In none of our patients, Contrast study was needed to diagnose the condition.

A consistent observation in all the 40 patients was that the actual intra-operative length (mean - 24.6mm) of the olive exceeded the length reported during ultrasonography (mean - 19.4mm). Ayaz et al. concluded that pyloric muscle thickness and pyloric diameter are age-dependent variables, while pyloric ratio which is the ratio between pyloric muscle thickness and pyloric diameter is independent of age at the time of presentation[11]. We also observed a larger olive in late presenters and most of these patients needed extension of the umbilical incision for approaching the pathological site.

Literature suggests that in as many as 30% of patients with IHPS, approach through umbilical incision makes access to the pathologic site difficult[1],[3]. In these cases, it is time- taking to deliver the thickened pyloric mass into the operative field and sometimes this manoeuvre leads to trauma to the serosa and the olive itself. Forceful retraction of the wound may cause tissue ischemia, increasing chances of post-operative wound infection. In such cases, it is therefore wise to increase the incision slightly to the right side to facilitate the delivery of the olive into the operative field. In our study, out of the 20 patients having surgery through UI, 11(55%) needed a slight extension towards the right side. The mean length of the UI was 2.75cm and the mean length of extension was 3mm to the right side, when needed. In three of our patients operated through UI, some serosal tear occurred in an attempt to deliver the olive through the wound. Extension of the incision to the right side was done in these patients.

By contrast, CI measured 3.0cm in length. It was extended in the two cases of mucosal perforation (one on duodenal side and the other on gastric side).

Mean intra-operative time with UI was 45.3 ±4.3 minutes but with CI, it was 42.2 ±3.6 minutes. Post-operative hospital stay, Post-operative emesis, Post-operative wound infection rate and analgesic requirement were comparable between the two groups and did not vary statistically. A few researchers have reported a longer intra-operative period and more wound infection in cases of UI[14]. Increased rate of wound infection in UI patients has necessitated the role of prophylactic antibiotics when using UI[15]. This is unlike our observation.

Compared to the observation of other investigators, higher incidence of post-operative emesis and longer time to tolerate feeds was found in our study. This was seen in both CI and UI groups. We could not find a definite cause for this, but a possible explanation could be the late presentation of our patients in sick state. These patients were, however, symptom-free after discharge and none of our patients needed redo-procedure for sub-optimal pyloromyotomy.


  Conclusion Top


Despite a slight increase in the mean operative time in cases of UI, it did not increase the morbidity or complication of pyloromyotomy. Also, it left an almost undetectable scar. It is a suitable alternative to CI to perform pyloromyotomy.



 
  References Top

1.
Tan KC, Bianchi A. Circumumbilical incision for pyloromyotomy. Br J Surg. 1986; 73:399.  Back to cited text no. 1
    
2.
Besson R, Sfeir R, Salakos C, Debeugny P. Congenital pyloric stenosis: a modified umbilical incision for pyloromyotomy. Pediatr Surg Int. 1997 ;12:224-5  Back to cited text no. 2
    
3.
Blümer RM, Hessel NS, van Baren R, Kuyper CF, Aronson DC. Comparison between umbilical and transverse right upper abdominal incision for pyloromyotomy. J Pediatr Surg. 2004; 39:1091-3.  Back to cited text no. 3
    
4.
Misra D, Mushtaq I. Surface umbilical pyloromyotomy. Eur J Pediatr Surg. 1998; 8:81-2.  Back to cited text no. 4
    
5.
Khan AR, Al-Bassam AR. Circumumbilical pyloromyotomy: larger pyloric tumours need an extended incision. Pediatr Surg Int. 2000; 16:338-41.  Back to cited text no. 5
    
6.
Fitzgerald PG, Lau GY, Langer JC, Cameron GS. Umbilical fold incision for pyloromyotomy. J Pediatr Surg. 1990; 25:1117-8.  Back to cited text no. 6
    
7.
Podevin G, Missirlu A, Branchereau S, Audry G, Gruner M. Umbilical incision for pyloromyotomy. Eur J Pediatr Surg. 1997; 7:8-10.  Back to cited text no. 7
    
8.
Poli-Merol ML, Francois S, Lefebvre F, Bouche Pillon-Persyn MA, Lefort G, Daoud S. Interest of umbilical fold incision for pyloromyotomy. Eur J Pediatr Surg.1996; 6:13-4.  Back to cited text no. 8
    
9.
Karri V, Bouhadiba N, Mathur A. Pyloromyotomy through circumbilical incision with fascial extension. Pediatr Surg Int. 2003;19:695-6.  Back to cited text no. 9
    
10.
Teele RL, Smith EH. Ultrasound in the diagnosis of hypertrophic pyloric stenosis. N Eng J Med.1977; 296:1149-50.  Back to cited text no. 10
    
11.
Ayaz ÜY, Dö?en ME, Dilli A, Ayaz S, Api A. The use of ultrasonography in infantile hypertrophic pyloric stenosis: does the patient’s age and weight affect pyloric size and pyloric ratio? Med Ultrason. 2015;17:28-33.  Back to cited text no. 11
    
12.
Macdessi J, Oates RK. Clinical diagnosis of pyloric stenosis: a declining art.BMJ. 1993; 306:553-5.  Back to cited text no. 12
    
13.
Yokomori K, Oue T, Odajima T, Baba N, Hashimoto D. Pyloromyotomy through a sliding umbilical window. J Pediatr Surg. 2006; 41:2066-8.  Back to cited text no. 13
    
14.
Leinwand MJ, Shaul DB, Anderson KD. The umbilical fold approach to pyloromyotomy: Is it a safe alternative to the right upper-quadrant approach? J Am Coll Surg. 1999; 189:362-7.  Back to cited text no. 14
    
15.
Ladd AP, Nemeth SA, Kirincich AN, Scherer LR 3rd, Engum SA, Rescorla FJ, West KW, Rouse TM, Billmire DF, Grosfeld JL. Supraumbilical pyloromyotomy: a unique indication for antimicrobial prophylaxis. J Pediatr Surg. 2005; 40:974-7.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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