LP is an emerging technique in many pediatric surgery centers as the routine procedure for the management of IHPS competing with the traditional technique. Many technical points have to be taken into consideration to facilitate certain steps and more importantly, to avoid catastrophic events. 3 Many modifications had been adopted to decrease the operative as well as the postoperative periods with minimizing the incidence of any complications.4 These modifications included the port site and number and the method of spreading the pylorus.5
Our technique of performing LP using a mosquito as a spreader through two stab incisions and one umbilical port for holding the telescope is one of these modifications. Direct instruments insertion through stabs, rather than ports, the use of special knives for “mass” incision, and soft grasper to hold the duodenum and fix the “mass” are all routinely adopted refinement of LP. However, one of the most difficult steps is the spreading of the “mass”. The advantage of our modification is that the surgeon’s hand is in full control of every step while using the forceps, exactly as in the open technique.
Some surgeons use Maryland for the spread. However, the problem with this is the un-constant translation of the surgeon’s force at the blades’ end of the instrument. The operator does not know exactly what’s going on in terms of the force, at the inside end. The weak force at spreading, the small range of blades opening, as well as the relatively short blades, make this technique, not the ideal one. Special spreaders have been described for this purpose, however, they are not widely available and relatively expensive.6 The use of the artery forceps in our study seems to be a good option because it is available, cheap, and more importantly, makes the operator in full control of the amount of force applied whether during the initial development of the groove over the incision site or during the spread of the “mass”.
Many modifications of the original LP were conducted by many surgeons to reach a safer technique with minimal complications. Modifications included the number, size, and type of trocars as well as the way of muscle spreading. A modification of LP was tailored by Anwar MO et al in 2016 who used two-port trocars (umbilical and right lower abdominal crease) with a stab epigastric incision for performing the pyloromyotomy. A Benson pyloric spreader was used to perform the pyloromyotomy after incising the seromuscular layer with an ophthalmic knife. 7
Another modification was conducted by A J Bufo et al in 1998 using one umbilical port and two lateral stab incisions on either side with a grasper introduced on the left holding the stomach and an arthroscopy knife to incise and the muscle on the right side; the muscle was dilated using a laparoscopic spreader.8
Pathak M et al added another modification in their study in the form of using only one umbilical port for insertion of the telescope together with the insertion of the operating instruments through direct stab incisions medial to the anterior axillary line below and above the umbilicus on the right and left respectively. Through the right one; they inserted a grasper holding the duodenum distal to the pylorus and through the left incision; they inserted a 3 mm electrocautery hook using its cutting mode in incising the pylorus through an avascular plane, deepening it until the incision can accommodate the hook from heel to tip. Then using a 3 mm pyloric spreader or Maryland; the incision was deepened and widened gently until a mucosal bulge occurs.9
The concerns that could be raised are mainly widening the insertion site port, whether the fascia or the skin, as well as pneumoperitoneum leak. In any of our cases, we noted that the incision in the abdominal wall had been widened during the opening of the mosquito, neither the fascia nor the skin. Probably the reason for that is that we keep the joint of the mosquito exactly at the port level. Keeping that, the working blades were long enough to do the job on the “mass” because of the small size of the abdominal cavity of the patients. The fascia is closed after the procedure using 4 “O” Vicryl. The other problem of pneumoperitoneum leak was not troublesome, and in case it happened, we used a towel clip to narrow the stab incision beside the mosquito and prevent the leak.