I would suggest reading the steps below, and then watch this brief clip:
[display_podcast]
Step 1: Have anesthesia place a 10 French red Robinson tube to decompress the stomach. This will be left in during the case to periodically decompress the stomach and, at the end, to insufflate air.
Step 2: Set the laparoscopic pressures to about 12 to 10.
Step 3: Set the flow to a setting of “2”. If this is set too high, it can interfere with ventilation.
Step 4: The child’s positioned sideways on the table. The head of the table, i.e. the patient’s right side is elevated and the table rotated toward the surgeon so that the patient’s feet are down and head is up.
Step 5: Frog leg the patient.
Step 6: The first incision is about a 3 mm incision through the umbilicus. Usually there is a fascial defect and an open technique can be used to place the small one step without the Veress needle. Both sides are firmly grasped and the 5 mm port – introduced or advanced in.
Step 7: 0° or 45° 4 mm scopes are used.
Step 8: A small incision is made laterally as if a line were drawn underneath the rib on the left side down to and past the pylorus. This is made just underneath the rib margin on the right side. The # 11 blade is advanced in nearly as far as it will go, appearing perhaps a little bit on the shallow side.
Step 9: The small grasper is advanced through the stab incision under direct vision and used to grasp the duodenum at the duodenal pyloric junction.
Step 10: A left upper quadrant incision is made on the line previously described through which the knife is advanced.
Step 11: The knife is advanced out to the second setting which is 2 mm which should be far less than the depth down to the mucosa.
Step 12: An incision is made from the white line well upon to the antrum.
Step 13: The knife is retracted back and the same instrument used to bluntly spread apart the muscle fibers and obtain mucosal outpouching.
Step 14: The spreader is advanced through the port that the knife was present in the left upper quadrant after it is removed.
Step 15: The spreader is used to spread the muscle fibers and obtain good mucosal outpouching.
Step 16: The spreader is advanced back in with a 2 cm thread. This is then grasped with the other grasper and laid over the incision to verify the length of it. This should be between 1.5 and 2 cm long.
Step 17: The spreader and grasper are used to grasp both sides and rock the pylorus back and forth to make sure that it is indeed split into two separate halves.
Step 18: Marcaine is injected at the entry sites under direct visualization.
Step 19: The stomach is then insufflated as previously described with a 10 French red Robinson catheter to make sure there is no bubbling or leakage.
Step 20: The two small stab incisions only need a steri-strip across the skin. The umbilical defect is closed with a figure of 8 suture of 4.0 or 3.0 Vicryl. A small gut suture is placed is in the skin at the umbilicus.