This study included 20 patients (16 male and four female) diagnosed with IHPS and managed with the modified Tan and Bianchi technique. The sex distribution found in our study is in agreement with that reported in the literature 13 and in the study by Zeidan et al.14. However, a higher male-to-female ratio of 196 : 33, 11 : 2, and 16 : 3 were described in the studies by Oomen et al.15, Yokomori et al. 16, and Bertozzi et al.17, respectively. As regards the age distribution, the mean age at presentation in this study was higher than the mean age in the study by Ordorica-Flores et al.18, in which it was 30±9 days. In contrast, our mean age was lower than the mean age of the extracavitary pyloromyotomy group in the study by Eltayeb et al.19, in which the mean age was 65.1±19.8 days.
In the present study, the mean operating time was significantly longer than that in patients operated using the RUQ incision in the literature 9, mostly because of a more difficult delivery of the pylorus through the umbilical incision. However, the operating times decreased with the surgeons’ cumulated experience using the umbilical incision. Our mean operative time was almost similar to that obtained with the Tan–Bianchi technique (52±14 min). With the exception of serosal tears that occurred in four cases (20%) compared with 4.4% in the study by Leinwand et al.20, this study did not show significant intraoperative complications. To make the delivery of the pylorus easier and to avoid excessive traction on the stomach, which may cause seromuscular lacerations, we have used some modifications to the umbilical approach described by Tan and Bianchi 5. We performed a transverse muscle-cutting incision; this gives a more direct access to the pylorus. Moreover, the pylorus was delivered by traction on the antrum, aided by squeezing of the palpable pylorus into the wound rather than by making traction alone. These modifications together with careful manipulation seem to be essential to avoid the intraoperative complications. One of the fatal and life-threatening intraoperative major complications, especially if not detected intraoperatively, is duodenal perforation, with the incidence ranging from 3.4 to 9.4% in the umbilical approach 9,21. In our study there was no incidence of mucosal perforations; this is in agreement with that reported by Yagmurlu et al.22, who showed that no cases of his open group had mucosal perforations. An incidence of 3% was reported in the studies by Fitzgerald et al.8, Leinwand et al.20, and Poli-Merol et al.10, and an incidence of 5% was reported in the study by Eltayeb and Othman 19.
Rapid advancement of the strength and amount of feeding following pyloromyotomy is attractive, as it can allow early discharge 23. In our study, feeding started after 6 h of the operation as recommended in the study by Graham et al.24 and Khan and Al-Bassam 25. In young infants, the umbilicus could be an area of colonization; the proximity of a circumumbilical incision to this area may contribute to an increased wound infection rate as reported by some authors 26,27. To avoid this risk, we performed good disinfection of the umbilicus before the routine preparation, correction of alkalosis preoperatively because alkalosis is thought to compromise immunity in infants 27. Moreover, we routinely used prophylactic antibiotics in all patients. However, our impression is that the umbilical incision should not be used with frank umbilical sepsis. As regards the length of postoperative hospital stay, it was equal to that reported in other studies using the umbilical technique 22,28. In our work, the postoperative course was uneventful, and the wound healed without complications in all patients. Excellent cosmetic results were obtained through this technique, with hardly visible scar, which did not grow with age.
Pyloromyotomy for IHPS using the modified Tan and Bianchi technique, entering the abdominal cavity through a transverse muscle-cutting incision after making a circumumbilical skin incision, is feasible, having excellent cosmetic results, accepted operative time, early initiation of postoperative feeding, and short hospital stay. Using this modification, we believe that we combine the advantage of circumumbilical incision with its better cosmetic results and the right transverse upper abdominal approach with its easy and feasible access to the pyloric mass. We recommend using this technique for large and/or distant pyloric masses. However, studies with larger number of patients and long-term follow-up are needed for better evaluation of this modification of the technique.
There are no conflicts on interest.
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