Implementation of a Quality Control System for Laparoscopic Pyloromyotomy in Hypertrophic Pyloric Stenosis: Hurdles and Pitfalls.

BACKGROUND:  In 2011, we implemented a new video-based system for quality control of laparoscopic pyloromyotomy. More than 3 years later, we evaluated how the implementation had gone and assessed its usability in predicting postoperative outcomes.

METHODS:  Four key point images or short video-segments were to be recorded perioperatively: prepyloromyotomy, parallel-mobility testing, perforation testing, and postpyloromyotomy. Data of all 134 patients undergoing laparoscopic pyloromyotomy from September 2011 to December 2014 were analyzed retrospectively. Five pediatric surgeons independently assessed the anonymized operative images for predicting reoperation and time to full-enteral feeding.

RESULTS:  The percentage of operations during which images were recorded increased from 45% in 2012 to 75% in 2014. Over the study period, one or more images were recorded in 89 of the 134 (66%) patients. In only 17 of 89 patients (19%), all four images were documented. The key point images or videos were made for prepyloromyotomy in 49%, parallel-mobility testing in 85%, perforation testing in 42%, and postpyloromyotomy in 94% of 89 patients. Five patients (3.7%) were reoperated for incomplete pyloromyotomy ( N  = 4) or mucosal perforation ( N  = 1). Images were recorded during the first operation in four of the five reoperated patients. The need of reoperation was correctly predicted for two of the four patients. Full-enteral feeding within 24 hours was correctly predicted for 67% of the patients (range: 47-88%).

CONCLUSION:  The increase in recorded images over the years is promising. The implementation of the quality control system did not contribute to a significant decrease in the complication rate, which was already very low. Still, reoperation or a protracted postoperative course could only be predicted with moderate accuracy from the operative images, therefore, for now the use of perioperative images in a medicolegal setting should be advised against. Improved compliance with image recording and better instructions for evaluating the images might improve the usefulness of perioperative images in, e.g., telementoring, education, and medicolegal practice.