The age-old question: lap versus open fill-in-the-blank. Today, class, we will be answering the question of lap versus open pyloromyotomy. When I trained circa 2012, my attendings were doing about half and half open vs. lap. Since finishing training, I haven’t done a single open pyloromyotomy but there are plenty of surgeons including at least one esteemed editor of this site, who still do (and advocate for) open pyloromyotomy. What factors help a surgeon’s journey in deciding laparoscopic versus open pyloromyotomy for pyloric stenosis? I’m glad you asked.
A recent meta-analysis1 concluded that there were no differences between the two approaches in major or minor complications, operative time, and length of stay. The laparoscopic approach was associated with a shorter time to full feeds but, let’s be realistic here, who cares if it doesn’t change length of stay? Any of these studies reviewed by this paper that found a faster time to full feeds found their ‘statistically significant difference’ in hours, not days which, of course, renders this difference clinically insignificant.
Interestingly, they cited one paper2 that described improved cosmesis from the laparoscopic incisions versus the open incision. As you might expect, these included the traditional right upper quadrant incision and not the periumbilical incision that many surgeons now employ.
Hypothetically speaking, if I had a 1 month old baby (jeez, this is just hypothetical, right?) with pyloric stenosis, which approach would I prefer? I think the answer is much simpler than you might expect. I would want the approach that my baby’s surgeon preferred. A comfortable, competent surgeon is better than not. This is not a situation where one approach is clearly beneficial over the other. Thankfully, this disease process has wonderful outcomes and these discussions are perfect for dogmatic lunchroom discussions and blogposts but probably don’t make much difference to the baby.
1Sathya C, Wayne C, Gotsch A, Vincent J, Sullivan KJ, Nasr A. Laparoscopic versus open pyloromyotomy in infants: a systematic review and meta-analysis. Pediatr Surg Int. 2017 Mar;33(3):325-333. doi: 10.1007/s00383-016-4030-y. Epub 2016 Dec 10. PMID: 27942806.
2Siddiqui S, Heidel RE, Angel CA, Kennedy AP Jr. Pyloromyotomy: randomized control trial of laparoscopic vs open technique. J Pediatr Surg. 2012 Jan;47(1):93-8. doi: 10.1016/j.jpedsurg.2011.10.026. PMID: 22244399.