Implementation of a Quality Control System for Laparoscopic Pyloromyotomy in Hypertrophic Pyloric Stenosis: Hurdles and Pitfalls
26 December 2017
04 June 2018
07 August 2018 (online)
Background In 2011, we implemented a new video-based system for quality control of laparoscopic pyloromyotomy. More than 3 years later, we evaluated how the implementation had gone and assessed its usability in predicting postoperative outcomes.
Materials and Methods Four key point images or short video-segments were to be recorded perioperatively: prepyloromyotomy, parallel-mobility testing, perforation testing, and postpyloromyotomy. Data of all 134 patients undergoing laparoscopic pyloromyotomy from September 2011 to December 2014 were analyzed retrospectively. Five pediatric surgeons independently assessed the anonymized operative images for predicting reoperation and time to full-enteral feeding.
Results The percentage of operations during which images were recorded increased from 45% in 2012 to 75% in 2014. Over the study period, one or more images were recorded in 89 of the 134 (66%) patients. In only 17 of 89 patients (19%), all four images were documented. The key point images or videos were made for prepyloromyotomy in 49%, parallel-mobility testing in 85%, perforation testing in 42%, and postpyloromyotomy in 94% of 89 patients. Five patients (3.7%) were reoperated for incomplete pyloromyotomy (N = 4) or mucosal perforation (N = 1). Images were recorded during the first operation in four of the five reoperated patients. The need of reoperation was correctly predicted for two of the four patients. Full-enteral feeding within 24 hours was correctly predicted for 67% of the patients (range: 47–88%).
Conclusion The increase in recorded images over the years is promising. The implementation of the quality control system did not contribute to a significant decrease in the complication rate, which was already very low. Still, reoperation or a protracted postoperative course could only be predicted with moderate accuracy from the operative images, therefore, for now the use of perioperative images in a medicolegal setting should be advised against. Improved compliance with image recording and better instructions for evaluating the images might improve the usefulness of perioperative images in, e.g., telementoring, education, and medicolegal practice.
- 1 Grant GA, McAleer JJ. Incidence of infantile hypertrophic pyloric stenosis. Lancet 1984; 1 (8387): 1177
- 2 Everett KV, Capon F, Georgoula C. , et al. Linkage of monogenic infantile hypertrophic pyloric stenosis to chromosome 16q24. Eur J Hum Genet 2008; 16 (09) 1151-1154
- 3 Ramstedt C. Zur operation der angeborenen pylorus stenose. Med Klin 1912; 8: 1702-1705
- 4 Tan KC, Bianchi A. Circumumbilical incision for pyloromyotomy. Br J Surg 1986; 73 (05) 399
- 5 Alain JL, Grousseau D, Terrier G. Extramucosal pyloromyotomy by laparoscopy. Surg Endosc 1991; 5 (04) 174-175
- 6 Oomen MW, Hoekstra LT, Bakx R, Ubbink DT, Heij HA. Open versus laparoscopic pyloromyotomy for hypertrophic pyloric stenosis: a systematic review and meta-analysis focusing on major complications. Surg Endosc 2012; 26 (08) 2104-2110
- 7 Hall NJ, Pacilli M, Eaton S. , et al. Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: a double-blind multicentre randomised controlled trial. Lancet 2009; 373 (9661): 390-398
- 8 Hall NJ, Eaton S, Seims A. , et al. Risk of incomplete pyloromyotomy and mucosal perforation in open and laparoscopic pyloromyotomy. J Pediatr Surg 2014; 49 (07) 1083-1086
- 9 Oomen MW, Hoekstra LT, Bakx R, Heij HA. Learning curves for pediatric laparoscopy: how many operations are enough? The Amsterdam experience with laparoscopic pyloromyotomy. Surg Endosc 2010; 24 (08) 1829-1833
- 10 Greason KL, Thompson WR, Downey EC, Lo Sasso B. Laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis: report of 11 cases. J Pediatr Surg 1995; 30 (11) 1571-1574
- 11 St Peter SD, Holcomb III GW, Calkins CM. , et al. Open versus laparoscopic pyloromyotomy for pyloric stenosis: a prospective, randomized trial. Ann Surg 2006; 244 (03) 363-370
- 12 Leclair MD, Plattner V, Mirallie E. , et al. Laparoscopic pyloromyotomy for hypertrophic pyloric stenosis: a prospective, randomized controlled trial. J Pediatr Surg 2007; 42 (04) 692-698
- 13 Way LW, Stewart L, Gantert W. , et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 2003; 237 (04) 460-469
- 14 Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995; 180 (01) 101-125
- 15 Buddingh KT, Nieuwenhuijs VB, van Buuren L, Hulscher JB, de Jong JS, van Dam GM. Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions. Surg Endosc 2011; 25 (08) 2449-2461
- 16 Callery MP. Avoiding biliary injury during laparoscopic cholecystectomy: technical considerations. Surg Endosc 2006; 20 (11) 1654-1658
- 17 Elakkary E, Ching K, Jacobs MJ. Spiral cystic duct: beware. JSLS 2006; 10 (04) 514-516
- 18 Strasberg SM. Avoidance of biliary injury during laparoscopic cholecystectomy. J Hepatobiliary Pancreat Surg 2002; 9 (05) 543-547
- 19 Avgerinos C, Kelgiorgi D, Touloumis Z, Baltatzi L, Dervenis C. One thousand laparoscopic cholecystectomies in a single surgical unit using the “critical view of safety” technique. J Gastrointest Surg 2009; 13 (03) 498-503
- 20 Vegunta RK, Rawlings AL, Jeziorczak PM. Methylene blue: a simple marker for intraoperative detection of gastroduodenal perforations during laparoscopic pyloromyotomy. Surg Innov 2010; 17 (01) 11-13
- 21 Ostlie DJ, Woodall CE, Wade KR. , et al. An effective pyloromyotomy length in infants undergoing laparoscopic pyloromyotomy. Surgery 2004; 136 (04) 827-832