الفهرس 
REVIEWANATOMY AND EMRYOLOGICALOnly 14 pages are availabe for public view
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Abstract
Summary and conclusion
IHPS remains one of the most common surgical
problems encountered in infants. Surgical management was
begun in 1892. Initial curative attempts consisted of
gastroenterostomy, with the first survival reported in 1898.
The initial surgical attempt directed at the pylorus itself
was attempted by Nicoll and consisted of crude forceps
dilatation of the lumen, accessed via a gastric incision, to
burst up the thickened pyloric ring by forcible
overstretching ”with a screwing motion” with forceps
(Hernanz-Schulman, 2003).
Although the initial operation performed in 1899 was
successful, subsequent complications included hemorrhage
and perforation. The surgical treatment of IHPS by
pyloroplasty technique was first described by Fredet and
Lesne in 1908 (JSLS, 2003). Pyloroplasty became the
procedure of choice in the 1st decade of the 20th century
and was applied by Dent, Heineke, Mikulicz, Nicoll,
Fredet, and Weber, with variations on the theme of incising
and resuturing the pyloric muscle (Hernanz-Schulman,
2003).
Summary and conclusion
103
In 1911, Conrad Ramstedt performed his first
operation for IHPS, and, having difficulty resuturing the
muscle, did not complete the process. The operation was
successful but with a protracted course of continued
postoperative vomiting. In his next patient, Ramstedt
decided not to suture the muscle, because ”one gained the
impression that the stenosis had not entirely been
overcome, and that the mucosa, perhaps as a result of the
transverse closure, was folded in the pylorus, causing
additional obstruction”(Hernanz-Schulman, 2003).
The Ramstedt procedure divides the hypertrophied
muscle, leaving the intact mucosa bulging through the
incision. Since the first description by Fredet and Lesne in
1908, and Ramstedt in 1912, the standard approach to a
pyloromyotomy has been the transverse RUQ approach,
generally performed with low associated morbidity and
mortality (Rao and Youngson, 1989; Hulka et al., 1997;
Fujimoto et al., 1999 ).
In spite the RUQ being the gold standard surgical
approach for pyloromyotomy; other approaches were
described in the literature. These include upper midline
Summary and conclusion
104
laparotomy, oblique incision and, recently, a
circumumbilical (UMB) incision (Sitsen et al., 1998).
With recent advances in minimally invasive
techniques, laparoscopic pyloromyotomy (LPM) has gained
increasing popularity. The first LPM was performed in
France in 1990. This was reported by Alain et al in
1991(Alain et al., 1991), and since then many institutions
have utilized this technique. The laparoscopic technique
has got the potential benefits of shorter hospital stay, early
tolerance of full feedings, less postoperative pain and
minimal postoperative complications (Caceres and Liu,
2003).
UMB and LPM approaches have been considered as
alternative approaches to the RUQ approach to improve
cosmetic results, but concerns remain about considerably
longer operating time, higher complication rate, and greater
cost. Despite the availability of reports comparing the RUQ
and UMB approaches(Leinwand et al., 1999; Khan and
Al-Bassam, 2000), LPM and RUQ approaches (Sitsen et
al., 1998) and LPM and UMB approaches (Fujimoto et al.,
1999 ; Greason et al., 1997; Zhang et al., 2002) .
Summary and conclusion
105
The first description of pyloromyotomy using the
laparoscopic approach appeared in the literature in 1991
(Alain et al., 1991). This report was followed by several
small institutional series describing the 3-port technique as
feasible and safe. The laparoscopic technique was preferred
over the open approach due to superior cosmetic result and
otherwise equal efficacy. Other series have compared the
approaches with mixed results, including longer operative
times and increased complication rates with the
laparoscopic approach. Other reports have found equal
operative times with decreased recovery time following the
laparoscopic approach and have concluded that laparoscopy
is the preferred technique. Still others have demonstrated
the operations to be equal in operating time, recovery time,
and complications (St. Peter et al., 2006).
SLAP is performed for the most part as an open
technique, and use the pneumoperitoneum only for the
identification of the pylorus and for the final mucosal and
bleeding check, avoiding all the disadvantages of a
prolonged pneumoperitoneum in infants. A further
advantage of the SLAP is the complete exploration of the
abdominal cavity, which shows any other possible
associated malformation (Lazar et al.,2008).
Summary and conclusion
106
Controlled trial of traumamyoplasty and
pyloromyotomy showed few complications, similar time to
postoperative feeding, and similar rates of post operative
emesis in both groups (Ordorica-Flores et al., 2001).
Endoscopy-guided balloon dilatation (EGBD)
introduced as a new method of nonoperative treatment for
infantile hypertrophic pyloric stenosis (IHPS) in 1988.
Experience confirms that balloon dilatation of IHPS is
feasible, but at present its results are not consistent enough
for recommendation of general use, Most patients failed
balloon dilation and were treated with pyloromyotomy
(Ogawa et al.1996).
Per oral endoscopic submucosal pyloromyotomy
appears to be technically feasible and effective. Potential
clinical applications, such as for infantile hypertrophic
pyloric stenosis, could be considered after confirmation of
safety in additional survival studies (Kawai et al., 2012).
Summary and conclusion
107
Conclusion:
Fredt-Ramstedt pyloromyotomy performed through a
right upper quadrant (RUQ) transverse incision is the gold
standard in treatment of infantile hypertrophic pyloric
Stenosis (IHPS) allover the past century. It is also the
easiest-to-master approach among all other options while
LPM and UMB approaches offered the potential of a
better cosmetic outcomE