title: Top to Bottom: A New Method for Assessing Adequacy of Laparoscopic Pyloromyotomy.
abstract: BACKGROUND
  Hypertrophic pyloric stenosis is a commonly encountered pediatric surgical issue. Initially treated with open surgical techniques, many pediatric surgeons have adopted the minimally invasive approach using laparoscopy. However, some concerns exist that the rate of incomplete pyloromyotomy is elevated in laparoscopy. We propose a new technique to assess the adequacy of laparoscopic pyloromyotomy.
  
  
  METHODS
  Adequacy of laparoscopic pyloromyotomy was assessed by confirming that the top of the serosa on one side of the pylorus has adequate freedom to reach the bottom of the muscle on other side. A retrospective review of patients undergoing laparoscopic pyloromyotomy confirmed by this method from March 2012 to January 2016 was conducted. Demographics, laboratory values on admission, and postoperative outcomes were collected. Descriptive statistics was utilized.
  
  
  RESULTS
  Thirty-three patients were included. Median age was 30 days (interquartile range [IQR]: 24, 47). Median pylorus length and thickness were 19 mm (IQR 17.3, 21) and 4.5 mm (IQR: 4.0, 4.8), respectively. Median time to first full feed was 8.5 hours (IQR: 6.6, 15.6). Twenty-three (69%) patients had postoperative emesis. Median length of stay postoperation was 26.5 hours (IQR: 21.1, 44.7). There were no reoperations for incomplete pyloromyotomy and no infections. On follow-up, 1 patient had prolonged postoperative emesis that resolved without further intervention and 1 patient on peritoneal dialysis before surgery had an incisional hernia that required operation in the setting of bilateral inguinal hernias.
  
  
  CONCLUSIONS
  In a small series, the top to bottom assessment appears to confirm adequacy of pyloromyotomy.
authors.affiliation: 1 Division of Pediatric Surgery , Phoenix Children's Hospital, Phoenix, Arizona.|2 Department of Surgery, Mayo Clinic Hospital , Phoenix, Arizona.
authors.forename: Maria E
authors.initials: ME
authors.lastname: Linnaus
authors.affiliation: 1 Division of Pediatric Surgery , Phoenix Children's Hospital, Phoenix, Arizona.
authors.forename: Crystal S
authors.initials: CS
authors.lastname: Langlais
authors.affiliation: 3 Department of Pediatric Surgery, Mott Children's Hospital, University of Michigan , Ann Arbor, Michigan.
authors.forename: Kevin N
authors.initials: KN
authors.lastname: Johnson
authors.affiliation: 1 Division of Pediatric Surgery , Phoenix Children's Hospital, Phoenix, Arizona.|2 Department of Surgery, Mayo Clinic Hospital , Phoenix, Arizona.
authors.forename: David M
authors.initials: DM
authors.lastname: Notrica
mesh_terms: D005260:Female; D005753:Gastric Mucosa; D006555:Hernia, Ventral / Q000453:epidemiology; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology; D020250:Postoperative Nausea and Vomiting / Q000453:epidemiology; D046248:Pyloric Stenosis, Hypertrophic / Q000601:surgery*; D011708:Pylorus / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: hypertrophic pyloric stenosis; incomplete pyloromyotomy; laparoscopic pyloromyotomy; technique