Pyloromyotomy

Pyloromyotomy is an operation that aims to permanently treat pyloric stenosis.

Pyloric stenosis is a condition which occurs during the early weeks of a child’s life. In this condition, the opening between the stomach and small intestine, known as the pylorus, becomes narrow due to thickening of the muscles around the pylorus. This leads to the restriction of the passage of food to the intestines from the stomach. Consequently, it becomes difficult for the child to digest anything properly, and he/she vomits after each feed. The loss of food may upset the electrolyte (salts and minerals) balance in the child's body.

The exact causes of this condition are not determined yet; however, genetic factors are believed to be responsible for its occurrence. This implies that the condition can be passed on from a parent to the child. Pyloric stenosis develops around the sixth week of a child’s life and is more common in boys than in girls. In pyloromyotomy, the surgeon cuts off the muscle fibres around the pylorus, which helps in the permanent treatment of pyloric stenosis.

This surgery is recommended in infants with pyloric stenosis. The following are the symptoms of this condition:

• Vomiting after having some food or after every feed, the vomit may look or smell curdled
• Strong and dynamic vomiting (like a fast stream/jet or missile)
• The child feels hungry and wants to eat or drink again after vomiting.
• Less frequent stools
• Presence of mucus in stools
• Abdominal movement in forms of waves before and after feeding
• Constipation
• Pain in abdomen
• Inability to gain weight
• Dehydration

The surgery is not recommended in the following cases:

• If the surgeon feels that the child is unfit for the procedure for some reason.
• If the child has electrolyte imbalance (it can be restored with proper feed).

The diagnosis of pyloric stenosis is usually done during a physical examination, wherein the doctor looks for the following symptoms:

• A hard lump (swelling) on the right side of the abdomen
• Straining of muscles (around the stomach) during or after drinking or eating

An ultrasound scan may also be performed to confirm the diagnosis of pyloric stenosis. Other tests such as blood tests and barium x-ray are also done as required.

The surgeon may have the following discussions with you before the surgery:

• Your concerns about the procedure (including advantages and complications).
• Any allergies or medical problems that your child has.
• You will be asked to sign a consent form to give permission to the doctor to perform the surgery.

As your child may be dehydrated due to constant vomiting, the surgeon will insert an intravenous (IV) drip to provide fluids and hydrate him/her. The surgery is performed only after the treatment of dehydration. The child may also need a nasogastric tube, which is inserted through the nose into the stomach for the collection of fluids from the stomach. The removal of stomach fluids prevents the child from feeling sick before and after surgery.

Pyloromyotomy is usually performed after the administration of general anaesthesia, which allows your child to be asleep or unconscious throughout the surgery. The child will be made to sit on your lap (to instil confidence and allay fears) during the administration of general anaesthesia. Anaesthesia may be given via an injection or in the gaseous form to breathe in/inhale. After this gaseous administration of anaesthesia, the child will fall asleep in a while, and after the intravenous administration of anaesthesia, the child will fall asleep immediately. Once the child is asleep, the medical staff will take him/her to the operation theatre/room. The pylorus is accessed by either of the two methods:

• Laparoscopic surgery: This method of surgery requires two to three small incisions on the abdomen. Through one of these cuts, the surgeon will place a rigid tube called a trocar to insert a camera inside the abdomen of the child. He/she will then fill the child’s abdomen with carbon dioxide gas to allow more space to perform the surgery. Additional trocars will be inserted via other incisions to insert small surgical instruments. The surgeon will use these instruments and camera in conjunction to perform the surgery.
• Open surgery: In this method, the surgeon will make a single long incision near the belly button of the child to reach the pylorus. This surgery is rarely performed as the healing time is usually longer.

In both the surgeries, the surgeon will cut the muscle fibres around the pylorus. This widens the opening into the intestine so that food can pass through easily.

Finally, the surgeon will close the incisions with stitches that dissolve in the body. 

The child will be taken to the recovery ward after the surgery for further care. The hospital stay will last for two to four days. The child will not be fed anything via mouth during the initial four to eight hours after surgery to allow the operated region to rest. During this period, the child will get nutrients via an IV drip. 

Gradually and over a day post-surgery, he/she will be started on breast milk or formula. It is normal for the child to vomit during the next few weeks of surgery, but not as severe as before the surgery.

The surgeon may give you the following instructions to take care of your child after the surgery:

• The surgeon may prescribe pain relief medicines for at least three days. You must give them to your child as per directions.
• Make the child wear loose clothes post-surgery because his/her abdomen may be sore for a few days.
• You have to ensure that the operated/surgical site is dry and cleaned to allow its proper healing.
• While bathing the child, ensure that the operated area does not get wet until it is completely healed.
• The child will gradually start gaining weight after the surgery with proper and balanced nutrition.
• Do not allow the child to sleep on their stomach; instead, teach them to sleep on their back.

Pyloromyotomy is usually successful in immediately reducing or stopping vomiting after feeding.

When to see the doctor?

You should contact the doctor if your child shows any of the following symptoms post-surgery:

• Body temperature over 37.5^oC, which does not subside with paracetamol.
• Persistent pain even after taking medicines
• Discharge from the incisions
• Signs of dehydration such as less frequent urination and lethargy
• Redness or inflammation at the operated site or surrounding areas

This surgery is also associated with the following complications:

• Vomiting even after surgery
• Infection at the surgical site
• Bleeding or pain at the site of surgery
• Reopening of the surgical wound
• Hernia at the surgical site
• A hole in the stomach wall
• Unattractive marks or scars

You will need to visit the hospital four to five days after the surgery to remove the dressings on the wound.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.