Choice of incision: the experience and evolution of surgical management of infantile hypertrophic pyloric stenosis.

PURPOSE: This study evaluated the impact of laparoscopic pyloromyotomy since it came into use at our institution in March 1999. MATERIALS AND METHODS: The recovery profiles and intraoperative and postoperative complications of 170 infants who underwent laparoscopic, semicircumumbilical incision, or right upper quadrant incision pyloromyotomies between March 1999 and April 2005 were analyzed. RESULTS: Eighty-one (48%) of operations were undertaken laparoscopically, 51 (30%) by traditional right upper quadrant incision, and 38 (22%) by semicircumumbilical incision. Patient group demographics were similar across all groups. There was no significant difference in overall complication rate between procedures: laparoscopic group, 12.3% (10/81); semicircumumbilical incision group, 18.4% (7/38); and right upper quadrant incision group, 9.8% (5/51). Early in the laparoscopic series there were 2 inadequate pyloromyotomies and 2 conversions to open procedures due to perforation (n = 1) and poor visibility (n = 1). Infections were more common with open surgery: laparoscopic, 1.2% (n = 1), right upper quadrant incision, 7.8% (n = 4), and semicircumumbilical incision, 13.2% (n = 5). Operative correction was required for herniation at 3 laparoscopic incision sites (3.6%), 2 semicircumumbilical incision sites (5.3%), and 2 right upper quadrant incision sites (3.9%). Patients who underwent laparoscopy returned to full feeds faster (laparoscopic, 18.1 hours; right upper quadrant incision, 28.1 hours; and semicircumumbilical incision, 28.9 hours) (P < 0.05), required less analgesia (laparoscopic, 2.1 doses; right upper quadrant incision, 4.0 doses; and semicircumumbilical incision, 4.3 doses) (P < 0.05), and had less emesis (laparoscopic, 1.6 episodes; right upper quadrant incision, 2.9 episodes; and semicircumumbilical incision, 3.5 episodes) (P < 0.05), resulting in faster discharge (laparoscopic, 2.0 days; right upper quadrant incision, 3.1 days; and semicircumumbilical incision, 3.2 days) (P < 0.05). CONCLUSION: Laparoscopic pyloromytomy is as effective and safe as open procedures and is associated with an improved recovery profile. We conclude that, where laparoscopic skills exist, laparoscopy should be the management of choice for hypertrophic pyloric stenosis.

Anesthesia for pediatric lithotripsy.

SUMMARY BACKGROUND: We describe 7 years experience of providing anesthesia for children undergoing lithotripsy in a hospital without pediatric inpatient facilities. A pediatric team, including anesthetist, pediatric nurse along with the equipment travel across the city with the patient from the children's hospital. As a high incidence of postoperative vomiting and discomfort was observed, the effect of increasing intraoperative analgesia and the use of antiemetic medication was examined. METHODS: From 1998 to 2004, 69 children (49 boys and 20 girls) were anesthetized for 120 procedures: 67 extracorporeal shock wave lithotripsy (ESWL) and 53 endosurgical procedures, consisting of percutaneous nephrolithotomy (29), ureteroscopic laser lithotripsy (17) and percutaneous bladder litholapaxy (7). The mean age was 5.4 years (10 months to 13 years) and weight 23.7 kg (7.1-59 kg). ESWL was performed initially with a Wolf Piezolith 2300, and after 1999, a Dornier Compact Delta. RESULTS: Increased administration of intraoperative analgesia resulted in reduced postoperative analgesia requirements in all the groups, with a significant reduction (P < 0.05) in the endosurgical group. Those who required more postoperative analgesia had more vomiting significantly (P < 0.05). CONCLUSIONS: For ESWL postoperative pain is dependent on the type of lithotriptor and the resultant stone fragment size created. This study suggests that postoperative vomiting could be reduced more effectively by the increased administration of intraoperative analgesia, than by a single intraoperative dose of an antiemetic drug.