Laparoscopic Pyloromyotomy

Disease summary:

• Pyloric stenosis is caused by hypertrophy of the pylorus to the point the gastric outlet becomes obstructed and leads to intense vomiting. Etiology is unclear but risk factors for pyloric stenosis include; being a male, maternal smoking during pregnancy, bottle feeding, genetic history and macrolide antibiotics. Pyloric stenosis most often is manifested between the third and sixth weeks of life with projectile vomiting after feeding.

Patient Considerations

• Disease Specific Considerations:

  • Pyloric Stenosis is a Medical Emergency, not a Surgical Emergency

    • Vomiting leads to hypochloremic, hypokalemic metabolic alkalosis.

      • Patients may be very dehydrated at presentation

        • Superimposed metabolic acidosis reflects severe hypovolemia and is an ominous sign

      • Metabolic alkalosis predisposes to post-op apnea

  • Patient must be appropriately resuscitated preoperatively. OU Anesthesia guidelines:

    • Bicarbonate ≤ 29

    • Chloride ≥ 100

    • Potassium ≥ 3.0

Case Planning

• Young patients are prone to heat loss

  • Pre-warm the room and place an underbody bair hugger or K-Thermia

• Airway: must have supplies to perform awake gastric suctioning prior to induction. Most use either 10fr OG or 18fr red rubber (*latex).

  • Suction should be performed with patient:

    • Supine

    • Left Lateral

    • Right Lateral

    • Prone

• Drugs/Infusions: these patients are NOT given narcotic intra-op.

• Monitors: standard

• Blood Availability: N/A

• PICU Bed Availability: N/A

Anesthetic Considerations:

• Induction: RSI with cricoid pressure

  • Evacuate the stomach prior to induction by passing an OG (awake) and suctioning in the supine, left/right lateral and prone positions.

  • Technique varies with attending; some use succinylcholine/atropine; some use Propofol bolus; some use Cisatracurium or rocuronium and reverse with Sugammadex.

  • Glycopyrrolate/Neostigmine may be used if twitches have returned by end of case

  • RN will provide CC pressure.

  • Place OG after anesthesia induction for intra-op gastric air push with 60cc Toomey syringe.

  • OG must be clamped after insufflation or the air will escape

• Positioning: you will turn patient caddy corner on OR bed.

• Maintenance

  • Maintenance of Anesthesia

    • Maintain with volatile anesthetic

    • No case-specific hemodynamic goals

  • Surgical Considerations

    • This procedure is frequently brief (<30 min)

• Emergence/Disposition

  • Patients should be fully reversed if neuromuscular blockade was given

  • Patients are a full stomach

    • Extubate Awake

• Post-Op Pain Management

  • NO NARCOTIC

  • Local per surgeon

  • Consider IV Acetaminophen

• Case-Specific Complications

  • Patients are full stomach

    • Avoid aspiration

  • Have a high degree of suspicion for post-operative apnea