33 Getting it Right First Time – Implementation of laparoscopic pyloromyotomy without a learning curve.
Waaka Moni-Nwinia, Ingo Jester, Dylan Wanaguru, Michael Singh, Max Pachl, Giampiero Soccorso, Suren Arul
Birmingham Children's Hospital, Birmingham, United Kingdom

Abstract

Aim:  laparoscopic pyloromyotomy (LP) is now a routine procedure for the treatment of pyloric stenosis.  Despite studies showing that it is safe, concerns have been raised that there is a significant learning curve; 2 papers (Leclair 2007, Hall 2009) quoted 6-10% for major complications including perforation and incomplete pyloromyotomy in LP.  Here we describe our approach to introducing a new laparoscopic procedure.

Method:  Five consultants in our unit who wished to introduce LP tasked one surgeon to pilot and establish the procedure before mentoring the others until they were confident to operate independently (1-3 cases each); all agreed to continue using exactly the same procedure.  The technique involved a 5mm infraumbilical telescope with 2 direct stab incisions to insert a 3 mm grasper, a Swann-Morton 69 blade and then a pyloromyotomy spreader.  The pyloromyotomy was considered adequate when there was bulging mucosa and independent movement of the edges.  Data was collected and cross-checked from consultant’s own logbooks, the hospital patient administration system and the M&M database. 

Results:  Between 1/1/2013 and 31/12/2017 there were 140 laparoscopic pyloromyotomies performed by 5 consultant firms (median age 27 days (13 -133days), M:F 121:19).  55% of procedures were performed by trainees.  There was 1 mucosal perforation (recognised and repaired immediately) and 1 inadequate pyloromyotomy that required re-operation 2 days later.  There were no injuries to other organs, problems with wound dehiscence or other significant complications.  The median time of discharge was 1 day (range 1-6 days).

Conclusion:  In our series the perforation rate was 0.7% and incomplete pyloromyotomy rate 0.7% which is as good as the best published series of  either open or laparoscopic pyloromyotomy.  We believe that our good outcome resulted from the coordinated implementation of the procedure using a single technique to reduce clinical variability, reduce complications and improve training.  


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