As a boy growing up with a scar cluster front and centre on my belly, I found I had several fixations which have never really left me.
- I was desperate to know what caused this scar, left by pyloric stenosis (“PS”) surgery I had when just 10 days old. Apart from my mother telling me several times that I had been “a little bit sick as a baby and a doctor had made me better” it wasn’t until much later in life that I pieced that puzzle together.
- I was also desperate to hide my belly from public view. I shrank from people’s inquisitive stares and inevitable questions and felt deeply embarrassed because I couldn’t handle, let alone answer them.
- Whenever I saw people in beach or gym attire (and with a bare midriff) I was ravenous in my search for anyone with a scar similar to mine – but never found anybody like me in that way until in my adult life.
Only in recent years have I learnt that this somewhat bizarre cluster of phobias and fixations is by no means unusual for survivors of infant surgery. As mentioned in a recent post, there are also many extroverts who totally escaped my problems – and often find them rather silly.
Obsession #3 has continued with me (and it seems with others in their more mature years). In recent years I have seen quite a number of people with what look like being scars from PS operations, and this is largely because I have learnt that this “procedure” is done using a number of surgical techniques. So my mind is now programmed to search for and recognize half a dozen scars! Yes, weird and whacky!
The development of the internet has birthed several forum sites where people like me can network and break out of their feelings of isolation and self-flaggelation. The web even allows us now to compare scars and to have many of our questions answered much more fully than my 1940s parents would ever have been able!
Recently Facebookers with an interest in their own or their child’s PS mentioned the sheer variety of scars from repairing PS, a fairly common condition remedied with a relatively simple technique. My own research of this whole subject area enabled me to attempt an answer –
The pyloric ring muscle usually sits under and behind the right (and exit) end of the stomach, so below the right ribcage. It can be fairly easily accessed from anywhere below the ribs and above the navel.
The navel (or umbilicus) itself is (or was once) often avoided as a point of access, especially if it hasn’t fully healed after the baby’s birth and as its folds are a haunt for germs. The umbilical incision (“Tan Bianchi” after the surgeons who promoted it) is a semi-circle incision usually over the top of the navel, sometimes extended by one or both horizontals (making it an omega sign): through this the pylorus is worked on. The Tan Bianchi incision is now often used as it allows open access but (if done well) leaves a minimal scar.
The keyhole op (“minimal access surgery” or MAS) was introduced in the 1990s: a 5mm probe (tube or “port”) through or near the navel inflates the belly and adds light, and then two other probes (3mm) higher up allow instruments to enter and do the work on the pylorus. In recent years “single port MAS” has been introduced by which everything is done through the one port at the navel. Special care with infection control is very important, and this technique comes with a higher number of infections, but it also leaves minimal scars and is therefore preferred by parents. MAS requires a higher level of training and skill than open surgery, but experienced surgeons can use it with similar results and complication profiles.
The open incision was and is still the easy one for surgeons, but growing numbers of younger pediatric surgeons have now learnt the umbilical and/or MAS techniques.
Open surgery involves cutting through layers of skin, fat, muscle, and the fine material that holds our abdominal bits and pieces in place, plus of course nerves and blood vessels. There are several layers of muscle forming the wall of the abdomen, each running in different directions to enable them to do a variety of tasks and to add toughness. Down the front and middle of the abdomen, running from the breastbone to the pubic region, is a strip of tough connective tissue called the “linea alba” or “white line”: it has less blood vessels and nerves and anchors the various muscle sheaths.
Conrad Ramstedt, who in 1912 pioneered and promoted the technique that is used to treat infant PS, used the median (or middle) incision down the linea alba that was and is still used for much (and especially major) abdominal surgery. It gives good access, can be easily extended, and avoids the complex muscle layers on either side.
Other surgeons preferred to avoid this area for relatively short incisions, as the linea alba’s poor blood supply slowed healing and therefore increased the risk of wound rupture. These doctors moved their vertical incision to the right, the “para-median” incision.
In the 1930s, two other incisions became popular for PS surgery. Both avoided the vertical openings which it was claimed came with increased exposure of internal organs, and more wound complications. By cutting through the several layers of muscle and repairing each separately, it was claimed that the wound was easier to control. One of these incisions was angled just under the right ribcage, the Kocher or “gridiron” incision. The other was transverse (“across”) and became the most popular one used for PS surgery to date. Transverse incisions are placed wherever the surgeon likes or locates the pylorus: some are almost at navel level, other horizontal just under the ribcage, and most in between.
Reading the journal articles that advocate the writers’ incision preference has led me to conclude that a surgeon’s choice seems to depend more on their classroom or craft training than on truly decisive benefits or hazards.
The development of the umbilical and MAS techniques has occurred only since 1990, urged on by the cosmetic benefits which are usually and typically urged on conservative and technique-oriented doctors by the concerned parents of unknowing babies.
Since writing this post I came across a website under the title of Common Abdominal Incisions. It sets out in (what I find) fascinating detail and in generally understandable English the various considerations, benefits and hazards regarding the incisions used for many of the commonly used abdominal surgeries, and what each incision involves. In the past I have sometimes found it necessary to “translate” the information given on a medical website, but in this case that seemed quite unnecessary.