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Chapter 46. Operative Management of Pyloric Stenosis: Pyloromyotomy

Benjamin Levi, MD; George B. Mychaliska, MD

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    AMA Citation
    Levi B, Mychaliska GB. Levi B, Mychaliska G.B. Levi, Benjamin, and George B. Mychaliska.Chapter 46. Operative Management of Pyloric Stenosis: Pyloromyotomy. In: Minter RM, Doherty GM. Minter R.M., Doherty G.M. Eds. Rebecca M. Minter, and Gerard M. Doherty.eds. CURRENT Procedures: Surgery New York, NY: McGraw-Hill; 2010. http://accessanesthesiology.mhmedical.com/content.aspx?bookid=419&sectionid=41482860. Accessed September 22, 2018.
    MLA Citation
    Levi B, Mychaliska GB. Levi B, Mychaliska G.B. Levi, Benjamin, and George B. Mychaliska.. "Chapter 46. Operative Management of Pyloric Stenosis: Pyloromyotomy." CURRENT Procedures: Surgery Minter RM, Doherty GM. Minter R.M., Doherty G.M. Eds. Rebecca M. Minter, and Gerard M. Doherty. New York, NY: McGraw-Hill, 2010, http://accessanesthesiology.mhmedical.com/content.aspx?bookid=419&sectionid=41482860.

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  • Projectile nonbilious emesis in an infant.
  • Palpable "olive" on physical examination.
  • "String sign" on an upper gastrointestinal series.
  • Pyloric muscle wall thickness ≥ 4 mm and pyloric channel length ≥ 16 mm on ultrasound examination.

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  • Severe hypochloremic, hypokalemic metabolic alkalosis.
  • Severe dehydration.

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  • For both open and laparoscopic procedures, the infant should be supine on the operating table.
  • Laparoscopic procedure.
    • The infant is positioned supine at the end of the operating table with appropriate padding.
    • The lower extremities are secured to the operating table in a frog leg position.

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  • Maintenance intravenous fluids are given until the infant is able to tolerate oral feedings.
  • Nothing by mouth for 6 hours followed by feeding every 3 hours:
    • For the first feeding, give 30 mL of full-strength formula; for the second feeding, give 60 mL of formula, and then increase amount as tolerated.
  • If the infant vomits, hold feeding and repeat the last tolerated volume in 3 hours.

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  • Mucosal perforation.
  • Incomplete myotomy.
  • Wound infection.

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