Pyloromyotomy Operative Note

Patient name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Sex: [Sex]

Date of surgery: [Date]

Time: [Time of incision / Time of closure]

Facility/OR: [Facility name and OR number]

Procedure: [Open Ramstedt pyloromyotomy / Laparoscopic pyloromyotomy]

Case type: [Elective / Urgent / Emergent]

Primary surgeon: [Name, credentials]

Assistant(s): [Assistant name(s) and role(s) / None]

Anesthesia type: [General endotracheal / Other]

Diagnosis and Indication

Preoperative diagnosis: [Infantile hypertrophic pyloric stenosis / Other specified diagnosis]

Postoperative diagnosis: [Same as preoperative / Updated diagnosis if changed intraoperatively]

Indication: [Brief statement linking clinical presentation to diagnostic confirmation]

Preoperative resuscitation: [Completed with correction of electrolyte and acid-base abnormalities / Not required / Incomplete due to [reason]]

Antibiotic prophylaxis: [Administered prior to incision: [agent, timing] / Not indicated per protocol / Withheld due to [reason]]

Intraoperative Summary

Estimated blood loss: [## mL / Minimal]; Drains: [None / Type, size, location]; Specimens: [None / Description]; Complications: [None / Description]; Counts: [Correct / Discrepancy noted: [description and resolution]]

Operative Findings

[Description of pyloric findings confirming IHPS: palpable hypertrophied olive, elongated/thickened pylorus, prominent pyloric muscle]

[Associated findings if any: gastric distension, serosal changes, anatomic variants, unexpected findings and clinical relevance] (Omit if none)

Description of Procedure

[Informed consent verified. Time-out performed. Patient under general endotracheal anesthesia, positioned supine with [positioning details]. OG/NG tube [placed and stomach decompressed / already in place]. Abdomen prepped and draped in sterile fashion.]

Open approach: [A [right upper quadrant transverse / supraumbilical / periumbilical] incision was made. Subcutaneous tissue divided, fascia incised, and peritoneum entered. The hypertrophic pylorus was identified and delivered into the wound. Pylorus exposed and oriented for myotomy.] (Include only if open approach performed)

Laparoscopic approach: [Pneumoperitoneum established to [pressure] mmHg via [open Hasson / Veress] technique. Ports placed: [camera port size and location], [working port(s) size and location]. The pylorus was stabilized by grasping the [duodenum / antrum] with an atraumatic grasper.] (Include only if laparoscopic approach performed)

Myotomy: [A longitudinal seromuscular incision was made on the anterior avascular surface of the pylorus starting at the gastric antrum, extending across the pyloric ring onto the proximal duodenum. The pyloric muscle fibers were spread bluntly using [pyloric spreader / Maryland dissector / blunt instrument] along the entire length until the mucosa was visibly exposed. Hemostasis achieved with [gentle pressure / bipolar cautery / none required].]

Myotomy completeness confirmation: [Objective indicator(s) documented: myotomy extended from antrum across pyloric ring to proximal duodenum; uniform mucosal bulge visible along entire myotomy; no residual muscle bridges; adequate separation at both ends] (Include at least one objective indicator. Do not leave blank; if not assessed, state reason.)

Mucosal integrity check: [Method: direct visual inspection along entire myotomy length. Adjunct testing if performed: [air insufflation via OG/NG with observation for bubbles / other].] Result: [Mucosa intact, no perforation identified / Perforation identified] (State result explicitly. Do not leave blank; if not assessed, state reason.)

(If perforation identified:) [Perforation location, estimated size, repair method, leak test result, decision regarding conversion to open, intraoperative antibiotics if administered, and impact on postoperative plan.]

Closure: [Fascia closed with [suture type/size, technique] if applicable. Skin closed with [subcuticular suture / skin adhesive / other]. Local anesthetic: [agent, volume] / Not performed. Sterile dressing applied.]

Disposition

Patient [stable / hemodynamically stable] at end of case. [Extubated in OR / Remained intubated due to [reason]]. Transferred to [PACU / NICU / PICU].

Postoperative Plan

Feeding pathway: Begin feeds [timing from end of procedure or when awake]. Feed type: [breast milk / formula / oral rehydration solution]. Advancement: [protocol-based stepwise / relaxed advancement as tolerated / ad lib after [X] hour NPO]. Emesis contingency: if vomiting, hold feeds [X] hours then resume previous tolerated level.

IV fluids: Continue maintenance fluids until adequate oral intake achieved.

Discharge criterion: Tolerates [number] consecutive goal feeds without significant emesis.

Pain control: Acetaminophen as primary analgesic per weight-based dosing.

Wound care: Remove dressing in [timeframe]. Keep incision clean and dry; sponge baths until [timeframe], then gentle shower without submersion.

Follow-up: [Timeframe]. Return precautions: persistent vomiting, signs of dehydration, fever, abdominal distension, wound erythema or drainage.

(If mucosal perforation repaired:) [Modified plan: NPO for [X] hours, IV antibiotics [agent, duration], consider contrast study prior to feeds, extended observation.]