Take Another Little Piece of My Pylorus Now, Baby

by Carly Schmidt, MD (’21)
Pediatric Surgery

Being 6 feet tall has its advantages- but nowhere else did I come to understand this than during my pediatric surgery elective. Towering over the surgeons I could clearly see the sterile field, whether I was scrubbed-in, or not. There is one surgery that sticks clearly in my memories from that month because even with my height advantage I needed to scrub-in in order to see this delicate procedure. I smiled under my mask at the scrub tech who adjusted the OR lights that hung over the field so I didn’t hit my head on them as I stepped up to the table, looking down at the little square of round baby belly visible under the blindingly blue sterile drapes. Across from me was the orthopedic surgery intern rotating through pediatrics this month. I tried to imagine what he must be thinking– his typical surgeries are big and loud and sweaty, they are emergent traumas with heavy blood loss, they require bone saws and hammering. And now, here he was, the only tools needed for this procedure could be held in his palm, and the blood loss when it was all said and done was estimated less than 3 milliliters.

This 8-week old on the operating table in front of us had presented to an outside hospital with the classic history for this diagnosis- projectile nonbilious, nonbloody emesis with every feed, no matter how much he was fed, how frequently, or with different formulas, and always seemed ferociously hungry after these emesis episodes. Most concerning to the mother was how few wet diapers he had made and she brought him to the hospital. An ultrasound confirmed the need for a pediatric surgeon, the baby was transferred, and optimized for the surgery.

Pyloric stenosis is both a clinical and radiologic diagnosis. It typically presents 2 weeks to 2 months of age with the history as above. The “olive” mass that medical students learn about is rarely felt until the baby is fully anesthetized and there is no abdominal muscle tone. Ultrasound confirms the diagnosis with measurements of the pyloric muscle thickness, and pyloric muscle length, which must be greater than 3mm and 14mm, respectively. Classic electrolyte derangements (tested frequently on board exams, but rarely seen in true clinical presentations) include a hypochloremic hypokalemic metabolic alkalosis, secondary to the loss of gastric hydrochloric acid and the kidney’s attempt to exchange potassium for hydrogen ions in an effort to correct this alkalosis.

Peering down at the baby’s exposed belly I watched the orthopedic intern, guided by the attending surgeon’s verbal instruction, delicately cut down through the layers of the abdominal wall (the names of which I have long since forgotten, a few beads of sweat building under my scrub cap as I realized they might ask me to recall these- to my great delight, they did not.) They mobilized the pylorus of the stomach out of this opening and made an incredibly small incision across the bulky pylorus muscle, verbally defining landmarks such as the “vein of Mayo” (a branch of the gastric vein which passes anterior to where the pylorus meets the duodenum) and avoiding them. They spread the muscle apart carefully, ensuring there was no damage to the mucosa underneath, which there was not. The pylorus was replaced, the abdominal wall closed, and the baby was sent to PACU recovery. The entire surgery from open to close lasted maybe 10 minutes, but I’m sure it felt like a lifetime to the baby’s waiting parents. 

Rounding with the surgical team the next day offered a unique sense of closure- getting to follow this baby from diagnosis to the OR to post-op to discharge. I left my elective with a much greater understanding of why pediatric surgeons willingly spend 7+ years in post-medical school training in order to practice in this career.