Association for Academic Surgery
Laparoscopic pyloromyotomy: comparing the arthrotomy knife to the Bovie blade

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Abstract

Background

Laparoscopic pyloromyotomy was performed at our institution using an arthrotomy knife until it became unavailable in 2010. Thus, we adapted the use of the blunt Bovie tip, which can be used with or without electrocautery to perform the myotomy. This study compared the outcomes between using the arthrotomy knife versus the Bovie blade in laparoscopic pyloromyotomies.

Materials and methods

Retrospective review was performed on all laparoscopic pyloromyotomy patients from October 2007 to September 2012. Arthrotomy knife pyloromyotomy patients were compared with those performed with the Bovie blade. Patient demographics, diagnostic measurements, electrolyte levels, length of stay, operative time, and complications were compared.

Results

A total of 381 patients were included, with 191 in the arthrotomy group and 190 in the Bovie blade group. No significant differences existed between groups in age, weight, gender, pyloric dimensions, electrolyte levels, or length of stay. Mean operative times were 15.8 ± 5.6 min with knife and 16.4 ± 5.3 min for Bovie blade (P = 0.24). In the arthrotomy knife group, there was one incomplete pyloromyotomy and one omental herniation. There was one wound infection in each group. Readmission rate was greater in the arthrotomy knife group (5.7%) versus the Bovie blade group (3.1%).

Conclusions

The Bovie blade appears to offer no objective disadvantages compared with the arthrotomy knife when performing laparoscopic pyloromyotomy.

Introduction

Hypertrophic pyloric stenosis is the most common surgical disease in infants [1]. Although pyloric stenosis has been recognized for centuries, curative pyloromyotomies have been performed since the early 1900s [2], [3]. The laparoscopic approach was first reported in 1991 [4], and since that time, the arthrotomy knife served as the predominant tool used to accomplish the myotomy [5], [6]. The laparoscopic approach has been the only option at our institution since completing enrollment in a randomized trial comparing the open to the laparoscopic approach in 2005 [7]. The arthrotomy knife was the only tool used to make the myotomy until it became unavailable in 2010, which required implementation of an alternative instrument. Thus, we improvised the use of the blunt long Bovie tip (Edge insulated blade electrode, 6.5 inch, Covidien Inc, Norwalk, CT; Fig. 1). Limited data exist on alternative methods used to perform laparoscopic pyloromyotomies. Hence, this retrospective review was conducted to compare the efficacy and safety of the new myotomy method compared with the arthrotomy knife.

Section snippets

Methods

On obtaining institutional review board approval (No. 12110504), a retrospective review was performed on all patients who underwent a laparoscopic pyloromyotomy with either the arthrotomy knife or Bovie blade for hypertrophic pyloric stenosis. All patients had ultrasound-confirmed diagnoses. The arthrotomy knife became unavailable at the end of March 2010. Thus, the inclusion dates were established from October 2007 to September 2012 to ensure the same period for each group. Arthrotomy knife

Technique

We perform the laparoscopic pyloromyotomy by placing the laparoscope through a step trochar via the patient's umbilicus. An 11-blade scalpel is used to make two stab incisions, one in the left upper quadrant and the other in the right upper quadrant of the abdomen. Three-millimeter instruments are then inserted through these incisions, without the use of trochars (Fig. 2). The pylorus is grasped and elevated. An incision is made through the muscular layers of the pylorus with care taken to not

Results

Of the 381 patients included, the number of patients in each group was comparable, with 191 arthrotomy knife pyloromyotomies and 190 Bovie blade pyloromyotomies. Standard demographics were similar between the groups (Table 1) There was also no difference in sonographic pyloric dimensions or electrolyte levels (Table 2). Mean operative times were 15.8 ± 5.6 min for the arthrotomy knife and 16.4 ± 5.3 min when using the Bovie blade (P = 0.24). Length of stay was 1.9 d for arthromy knife and 1.8 d

Discussion

Laparoscopic pyloromyotomy is well established as an effective technique with superior cosmetic results to the open approach [7], [8]. In fact, most parents surveyed note that they would pay more for their child to have smaller pyloromyotomy scars [9]. Fortunately, when production of the retractable knife ceased, other techniques were adopted that spared the need for the former laparotomy incisions. The use of a Bovie blade in this regard seems to be a favorable alternative.

Internationally,

Conclusions

The blunt Bovie blade is a comparable replacement to the arthrotomy knife when performing laparoscopic pyloromyotomy. Further study is needed to determine if the Bovie blade is superior to other techniques and tools developed since the extinction of the arthrotomy knife.

Acknowledgment

Sources of Funding: None.

Authors' contributions: S.D.P. contributed to study design and critical revision; P.G.T. contributed to article writing, data collection, and analysis; N.E.S. contributed to data collection.

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