506
F. R. Sykes
this reason a separate incision was made in the remaining cases. The indications for this procedure are indentical to those of the usual loop colostomy, but in the presence of complete obstruction distal to the colostomy, the dangers associated with a closed loop would occur. Even in the presence of partial obstruction, this colostomy would not enable complete clearance of the faecal contents of the bowel immediately proximal to the obstruction, hence, it would not be advised in the management of obstruction. However, the place of this procedure is in those instances when complete rest of the distal colon is required, such as in the presence of a faecal fistula. For defunctioning the colon in order to protect an anastomosis it is ideal, producing a complete exclusion,
yet not requiring a second operation t o clear the colostomy. Because the faeces drain through a tube into a bag, the patient is spared the discomfort of a colostomy, which, particularly in the immediate postoperative period, is hard to manage. The emotional stress to which many patients are submitted by the appearance of a colostomy is avoided by this technique and the inevitable odour is reduced by the closed drainage technique described. The technique of transcutaneous defunctioning colostomy is proposed as an alternative t o both loop colostomy and a caecostomy, overcoming the disadvantages of both techniques and having few, if any, drawbacks of its own. Paper accepted I I October 1978.
Br. J. Surg. Vol. 66 (1979) 506
Pyloromyotomy forceps A. G . J O H N S O N A N D F. K H A N ” A NUMBER of different instruments have been devised for performing pyloromyotomy (Ramstedt’s operation) in infants (Quinby, 1966; Benson, 1969). The best known is the Dennis Browne forceps (Browne, 1951), but this is only useful at the end of the operation when the muscle has been well separated, because its tips are 3 mm apart when closed. Many surgeons
insert a small curved haemostat into the scalpel incision to separate the circular muscle fibres, but this is often too wide and is smooth on the outside and tends to slip. The new forceps (GU Manufacturing Co. Ltd, Plympton Street, London) illustrated in Fig. 1 is serrated on the outside and closes to form a sharp ‘keel’ (inset) which can be inserted into the initial scalpel incision. The curve of the blades follows the shape of the pyloric muscle in longitudinal section and the tip is blunt so as not to damage the thin fornix of the duodenal wall at the end of the incision. For the past 3 years the forceps has been found useful by more experienced surgeons as well as by registrars learning the operation for the first time.
References BENSON c. D. MUSTARD
(1969) Prepyloric and pyloric obstruction. In:
w.
T., RAVITCH M. M., SNYDER
w.
H.
et al. (ed.)
Paediatric Surgery. Chicago, Year Book, vol. 2, p. 795. BROWNE D.
(1951) The technique of Ramstedt’s operation.
Proc. R . Soc. Med. 44, 1057-1059.
w. c. (1966) Complete pyloromyotomy without duodenal perforation. Surgery 59, 627-630.
QUINBY
Paper accepted 17 January 1979.
Fig. 1. The forceps, with close-up views of the tips.
* Professorial Unit of Surgery, Charing Cross Hospital Medical School, Fulhani Palace Road, London.
F. R. Sykes
this reason a separate incision was made in the remaining cases. The indications for this procedure are indentical to those of the usual loop colostomy, but in the presence of complete obstruction distal to the colostomy, the dangers associated with a closed loop would occur. Even in the presence of partial obstruction, this colostomy would not enable complete clearance of the faecal contents of the bowel immediately proximal to the obstruction, hence, it would not be advised in the management of obstruction. However, the place of this procedure is in those instances when complete rest of the distal colon is required, such as in the presence of a faecal fistula. For defunctioning the colon in order to protect an anastomosis it is ideal, producing a complete exclusion,
yet not requiring a second operation t o clear the colostomy. Because the faeces drain through a tube into a bag, the patient is spared the discomfort of a colostomy, which, particularly in the immediate postoperative period, is hard to manage. The emotional stress to which many patients are submitted by the appearance of a colostomy is avoided by this technique and the inevitable odour is reduced by the closed drainage technique described. The technique of transcutaneous defunctioning colostomy is proposed as an alternative t o both loop colostomy and a caecostomy, overcoming the disadvantages of both techniques and having few, if any, drawbacks of its own. Paper accepted I I October 1978.
Br. J. Surg. Vol. 66 (1979) 506
Pyloromyotomy forceps A. G . J O H N S O N A N D F. K H A N ” A NUMBER of different instruments have been devised for performing pyloromyotomy (Ramstedt’s operation) in infants (Quinby, 1966; Benson, 1969). The best known is the Dennis Browne forceps (Browne, 1951), but this is only useful at the end of the operation when the muscle has been well separated, because its tips are 3 mm apart when closed. Many surgeons
insert a small curved haemostat into the scalpel incision to separate the circular muscle fibres, but this is often too wide and is smooth on the outside and tends to slip. The new forceps (GU Manufacturing Co. Ltd, Plympton Street, London) illustrated in Fig. 1 is serrated on the outside and closes to form a sharp ‘keel’ (inset) which can be inserted into the initial scalpel incision. The curve of the blades follows the shape of the pyloric muscle in longitudinal section and the tip is blunt so as not to damage the thin fornix of the duodenal wall at the end of the incision. For the past 3 years the forceps has been found useful by more experienced surgeons as well as by registrars learning the operation for the first time.
References BENSON c. D. MUSTARD
(1969) Prepyloric and pyloric obstruction. In:
w.
T., RAVITCH M. M., SNYDER
w.
H.
et al. (ed.)
Paediatric Surgery. Chicago, Year Book, vol. 2, p. 795. BROWNE D.
(1951) The technique of Ramstedt’s operation.
Proc. R . Soc. Med. 44, 1057-1059.
w. c. (1966) Complete pyloromyotomy without duodenal perforation. Surgery 59, 627-630.
QUINBY
Paper accepted 17 January 1979.
Fig. 1. The forceps, with close-up views of the tips.
* Professorial Unit of Surgery, Charing Cross Hospital Medical School, Fulhani Palace Road, London.
