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