Umbilical Fold Incision for Pyloromyotomy By Peter
G. Fitzgerald,
George
Y.P.
Lau,
Jacob
Hamilton, l A B-year experience with 100 infants undergoing pyloromyotomy was reviewed. Fifty infants who had a standard right upper quadrant incision were compared with 50 infants in whom an umbilical fold incision was used. The groups did not differ significantly with respect to length of operating time, hospital stay, or intraoperative complications. Wound complications were infrequent and minor in both groups. The umbilical fold incision permits excellent access to the pylorus, while leaving an almost undetectable scar. @ 1990 by W.B. Saunders Company.
C. Langer,
and
Gordon
S. Cameron
Ontario subcuticular absorbable sutures and a pressure dressing was applied. Figure I illustrates the technique. The RUQ group had the standard muscle splitting incision described by Robertson.’ The muscle layers were closed with chromic catgut, and the skin was closed with either subcuticular plain catgut or nylon and steri-strips. No patients in the RUQ group received antibiotics preoperatively. All values are expressed as mean + standard deviation and all analyses were done by using either a two-tailed Student’s t test or xz analysis. RESULTS
INDEX
WORD:
Pyloromyotomy.
T
HE ACCEPTED treatment for infantile hypertrophic pyloric stenosis is a Ramstedt pyloromyotomy. A variety of approaches to the pylorus have been described, including upper midline, transverse rectus, and Robertson muscle splitting incisions.‘V2 In 1986, Tan and Bianchi3 described the umbilical fold (UMB) incision, with division of the linea alba, in a series of 40 infants undergoing pyloromyotomy. This technique resulted in an acceptable complication rate and a cosmetically superior result. We evaluated the results of the UMB incision in 50 infants, and retrospectively compared them with a group of 50 infants who underwent pyloromyotomy through a traditional Robertson right upper quadrant (RUQ) incision. Operating time, complication rates, and final cosmetic results were assessed. MATERIALS
AND
METHODS
Clinical Material Hospital charts of patients undergoing pyloromyotomy were reviewed for the period between January 1984 and November 1988. The first 50 cases where a RUQ incision had been used, and the first 50 cases where an UMB incision was used were assessed. Charts were reviewed as they became available from Medical Records; therefore, they were not necessarily consecutive. Cases in which there was a history of prior operative procedures or significant medical illness were excluded.
Technique For the UMB incision, the umbilicus was cleansed preoperatively with betadine on the ward. Early in the series 14 patients in this group received a preoperative dose of intravenous cloxacillin prophylactically. Skin hooks were placed at the lateral margins of the superior umbilical fold. An incision was made along the fold and carried down onto the linea alba with sharp dissection. The linea alba was then divided either longitudinally (49) or transversely (l), the peritoneum was opened, and the pylorus delivered. A Ramstedt pyloromyotomy was performed and the pylorus was returned to the peritoneal cavity. The fascia was then closed with either Dexon (36) Prolene (12). or Vicryl (2). The skin was closed with interrupted Jourm/
of Pediatric
Surgery,
Vol 25,
No 11 (November),
1990:
pp 1117-l
There were no significant differences between the two groups with regard to sex, age of presentation, duration of symptoms, estimation of dehydration on admission, electrolytes, and admission weight (Table 1). Mean operating times were 35 -e 12 minutes for the UMB group and 33 k 9 minutes for the RUQ group (NS, t test). In the UMB group 23 of 50 cases were done primarily by resident staff, compared with 25 of 50 cases in the RUQ group (NS, x2). Intraoperative complications for the UMB group consisted of two mucosal perforations and three minor serosal tears; the RUQ group had one mucosal perforation and one minor serosal tear. There were no significant differences in postoperative feeding tolerance. Fourteen infants in the UMB group and 12 infants in the RUQ group had no postoperative vomiting (NS, x2). In comparing infants with vomiting, we found no significant difference in the time to the last episode of vomiting (UMB, 1.2 + 0.6 days; RUQ, 1.3 +-0.5 days; NS, t test). Length of postoperative hospital stay was similiar for both groups (UMB, 2.2 * 1.2 days; RUQ, 2.3 t 1.3 days: NS, t test). Patient follow-up ranged from 1 week to 12 months. There were no significant differences in the incidence of wound complications between the two groups. Wound complications in the UMB group included two wound infections, three minor stitch abscesses, and one hyper-
From the Division of Pediatric Surgery, Department of Surgery, McMaster University, Hamilton, Ontario. Presented at the 2lst Annual Meeting of the Canadian Association of Paediatric Surgeons, Edmonton, Alberta, September 20-23. 1989. Address reprint requests to J.C. Langer, MD, Rm 4E2, McMaster University Medical Centre. 1200 Main St W, Hamilton, Ontario L8N 325. Canada. o 1990 by W.B. Saunders Company. 0022-3468/90/2511-0003$03.00/0 118
1117
FITZGERALD
1119
ET AL
ill 0
E
Fig 1. (A) A superior UMB incison is made, and (61 the linea alba exposed. The linea alba is divided either (Cl transversely or (D) longitudinally. (El The peritoneum is entered. the pylorus delivered and a pyloromyotomy done. (F) After fascial closure, the skin is closed with interrupted subcuticular sutures and steristrips are applied.
trophic scar. One of the infants who developed a wound infection had received prophylactic antibiotics. In the RUQ group there was one wound infection, one minor stitch abscess, one hematoma, and one hypertrophic scar. None of the wound infections required drainage. There were no cases of wound dehiscence or ventral hernia. The RUQ incision resulted in a visible but acceptable scar. The UMB incision left an almost undetectable scar, which became well incorporated into the umbilicus (Fig 2). DISCUSSION
The UMB incision represents a new approach to the pylorus that is safe and produces an excellent final cosmetic result. The complication rates for both the UMB and RUQ groups were comparable to those seen in larger series.4-6 Although the umbilicus has been implicated as a possible source of bacteria for the Table
Fig 2.
UMB RUCI
Age (d) 39i 38+
14 19
incision
1 month
after
surgery.
development of wound infections after pyloromyotomy,6 we found no significant increase in infectious complications when the UMB incision was used. However, we do believe adequate preoperative cleansing of the umbilicus is essential when using the UMB incision. Prophylactic antibiotics for pyloromyotomy have been advocated to reduce the incidence of wound infections.‘,’ Unfortunately, the sporadic use of antibiotics in this series did not allow us to draw any conclusions about its usefulness. Because of the low incidence of wound infections after pyloromyotomy using either incision, it would require a large number of patients in each group to study this question in a controlled trial. These data demonstrate that the UMB incision permits excellent access to the pylorus, without affecting operating time or increasing the incidence of intraoperative complications. Postoperative complications are infrequent and comparable to those encountered when using a traditional Robertson incision. The main advantage of the UMB incision is that it produces an almost undetectable scar and is clearly superior to the standard RUQ incision in terms of the long-term cosmetic result.
1. Admission
Data Dehydration
sex Group
UMB
M
F
32 40
12 10
Duration of Symptoms
(d)
9+8 7*9
0%
5%
10%
Admission Weight (kg)
7 9
33 31
10 8
4.0 + .6 4.1 r6
REFERENCES 1. Randolph JG: The evolution of an ideal surgical incision for pyloric stenosis. Arch Surg 93:489-491, 1966 2. Robertson DE: Congenital pyloric stenosis. Ann Surg 112:687689.1940 3. Tan KC, Bianchi A: Circumumbilical incision for pyloromyotomy. Br J Surg 73:399,1986 4. Scharli A, Sieber WK, Kiesewetter WB: Hypertrophic pyloric stenosis at the Children’s Hospital of Pittsburgh from 1912 to 1967. J Pediatr Surg 4: 108- 114, 1969
5. Benson CD, Lloyd JR: Infantile pyloric stenosis: A review of 1120cases. Am J Surg 107:429-433, 1964 6. Zeidan B, Wyatt J, MacKersie A, et al: Recent results of treatment of infantile hypertrophic pyloric stenosis. Arch Dis Child 63:1060-1064, 1988 7. Fitzgerald RJ: Comment, The results of Ramstedt’s operation: Room for complacency? Ann R Co11Surg Engl66:449, 1984 8. Gray DW, Gear MW, Stevens DW: The results of Ramstedt’s operation: Room for complacency? Ann R Co11 Surg Engl 66:280282.1984
G. Fitzgerald,
George
Y.P.
Lau,
Jacob
Hamilton, l A B-year experience with 100 infants undergoing pyloromyotomy was reviewed. Fifty infants who had a standard right upper quadrant incision were compared with 50 infants in whom an umbilical fold incision was used. The groups did not differ significantly with respect to length of operating time, hospital stay, or intraoperative complications. Wound complications were infrequent and minor in both groups. The umbilical fold incision permits excellent access to the pylorus, while leaving an almost undetectable scar. @ 1990 by W.B. Saunders Company.
C. Langer,
and
Gordon
S. Cameron
Ontario subcuticular absorbable sutures and a pressure dressing was applied. Figure I illustrates the technique. The RUQ group had the standard muscle splitting incision described by Robertson.’ The muscle layers were closed with chromic catgut, and the skin was closed with either subcuticular plain catgut or nylon and steri-strips. No patients in the RUQ group received antibiotics preoperatively. All values are expressed as mean + standard deviation and all analyses were done by using either a two-tailed Student’s t test or xz analysis. RESULTS
INDEX
WORD:
Pyloromyotomy.
T
HE ACCEPTED treatment for infantile hypertrophic pyloric stenosis is a Ramstedt pyloromyotomy. A variety of approaches to the pylorus have been described, including upper midline, transverse rectus, and Robertson muscle splitting incisions.‘V2 In 1986, Tan and Bianchi3 described the umbilical fold (UMB) incision, with division of the linea alba, in a series of 40 infants undergoing pyloromyotomy. This technique resulted in an acceptable complication rate and a cosmetically superior result. We evaluated the results of the UMB incision in 50 infants, and retrospectively compared them with a group of 50 infants who underwent pyloromyotomy through a traditional Robertson right upper quadrant (RUQ) incision. Operating time, complication rates, and final cosmetic results were assessed. MATERIALS
AND
METHODS
Clinical Material Hospital charts of patients undergoing pyloromyotomy were reviewed for the period between January 1984 and November 1988. The first 50 cases where a RUQ incision had been used, and the first 50 cases where an UMB incision was used were assessed. Charts were reviewed as they became available from Medical Records; therefore, they were not necessarily consecutive. Cases in which there was a history of prior operative procedures or significant medical illness were excluded.
Technique For the UMB incision, the umbilicus was cleansed preoperatively with betadine on the ward. Early in the series 14 patients in this group received a preoperative dose of intravenous cloxacillin prophylactically. Skin hooks were placed at the lateral margins of the superior umbilical fold. An incision was made along the fold and carried down onto the linea alba with sharp dissection. The linea alba was then divided either longitudinally (49) or transversely (l), the peritoneum was opened, and the pylorus delivered. A Ramstedt pyloromyotomy was performed and the pylorus was returned to the peritoneal cavity. The fascia was then closed with either Dexon (36) Prolene (12). or Vicryl (2). The skin was closed with interrupted Jourm/
of Pediatric
Surgery,
Vol 25,
No 11 (November),
1990:
pp 1117-l
There were no significant differences between the two groups with regard to sex, age of presentation, duration of symptoms, estimation of dehydration on admission, electrolytes, and admission weight (Table 1). Mean operating times were 35 -e 12 minutes for the UMB group and 33 k 9 minutes for the RUQ group (NS, t test). In the UMB group 23 of 50 cases were done primarily by resident staff, compared with 25 of 50 cases in the RUQ group (NS, x2). Intraoperative complications for the UMB group consisted of two mucosal perforations and three minor serosal tears; the RUQ group had one mucosal perforation and one minor serosal tear. There were no significant differences in postoperative feeding tolerance. Fourteen infants in the UMB group and 12 infants in the RUQ group had no postoperative vomiting (NS, x2). In comparing infants with vomiting, we found no significant difference in the time to the last episode of vomiting (UMB, 1.2 + 0.6 days; RUQ, 1.3 +-0.5 days; NS, t test). Length of postoperative hospital stay was similiar for both groups (UMB, 2.2 * 1.2 days; RUQ, 2.3 t 1.3 days: NS, t test). Patient follow-up ranged from 1 week to 12 months. There were no significant differences in the incidence of wound complications between the two groups. Wound complications in the UMB group included two wound infections, three minor stitch abscesses, and one hyper-
From the Division of Pediatric Surgery, Department of Surgery, McMaster University, Hamilton, Ontario. Presented at the 2lst Annual Meeting of the Canadian Association of Paediatric Surgeons, Edmonton, Alberta, September 20-23. 1989. Address reprint requests to J.C. Langer, MD, Rm 4E2, McMaster University Medical Centre. 1200 Main St W, Hamilton, Ontario L8N 325. Canada. o 1990 by W.B. Saunders Company. 0022-3468/90/2511-0003$03.00/0 118
1117
FITZGERALD
1119
ET AL
ill 0
E
Fig 1. (A) A superior UMB incison is made, and (61 the linea alba exposed. The linea alba is divided either (Cl transversely or (D) longitudinally. (El The peritoneum is entered. the pylorus delivered and a pyloromyotomy done. (F) After fascial closure, the skin is closed with interrupted subcuticular sutures and steristrips are applied.
trophic scar. One of the infants who developed a wound infection had received prophylactic antibiotics. In the RUQ group there was one wound infection, one minor stitch abscess, one hematoma, and one hypertrophic scar. None of the wound infections required drainage. There were no cases of wound dehiscence or ventral hernia. The RUQ incision resulted in a visible but acceptable scar. The UMB incision left an almost undetectable scar, which became well incorporated into the umbilicus (Fig 2). DISCUSSION
The UMB incision represents a new approach to the pylorus that is safe and produces an excellent final cosmetic result. The complication rates for both the UMB and RUQ groups were comparable to those seen in larger series.4-6 Although the umbilicus has been implicated as a possible source of bacteria for the Table
Fig 2.
UMB RUCI
Age (d) 39i 38+
14 19
incision
1 month
after
surgery.
development of wound infections after pyloromyotomy,6 we found no significant increase in infectious complications when the UMB incision was used. However, we do believe adequate preoperative cleansing of the umbilicus is essential when using the UMB incision. Prophylactic antibiotics for pyloromyotomy have been advocated to reduce the incidence of wound infections.‘,’ Unfortunately, the sporadic use of antibiotics in this series did not allow us to draw any conclusions about its usefulness. Because of the low incidence of wound infections after pyloromyotomy using either incision, it would require a large number of patients in each group to study this question in a controlled trial. These data demonstrate that the UMB incision permits excellent access to the pylorus, without affecting operating time or increasing the incidence of intraoperative complications. Postoperative complications are infrequent and comparable to those encountered when using a traditional Robertson incision. The main advantage of the UMB incision is that it produces an almost undetectable scar and is clearly superior to the standard RUQ incision in terms of the long-term cosmetic result.
1. Admission
Data Dehydration
sex Group
UMB
M
F
32 40
12 10
Duration of Symptoms
(d)
9+8 7*9
0%
5%
10%
Admission Weight (kg)
7 9
33 31
10 8
4.0 + .6 4.1 r6
REFERENCES 1. Randolph JG: The evolution of an ideal surgical incision for pyloric stenosis. Arch Surg 93:489-491, 1966 2. Robertson DE: Congenital pyloric stenosis. Ann Surg 112:687689.1940 3. Tan KC, Bianchi A: Circumumbilical incision for pyloromyotomy. Br J Surg 73:399,1986 4. Scharli A, Sieber WK, Kiesewetter WB: Hypertrophic pyloric stenosis at the Children’s Hospital of Pittsburgh from 1912 to 1967. J Pediatr Surg 4: 108- 114, 1969
5. Benson CD, Lloyd JR: Infantile pyloric stenosis: A review of 1120cases. Am J Surg 107:429-433, 1964 6. Zeidan B, Wyatt J, MacKersie A, et al: Recent results of treatment of infantile hypertrophic pyloric stenosis. Arch Dis Child 63:1060-1064, 1988 7. Fitzgerald RJ: Comment, The results of Ramstedt’s operation: Room for complacency? Ann R Co11Surg Engl66:449, 1984 8. Gray DW, Gear MW, Stevens DW: The results of Ramstedt’s operation: Room for complacency? Ann R Co11 Surg Engl 66:280282.1984
