The laparoscopic approach for pyloromyotomy is gaining in popularity, mainly as a result of its cosmetic advantage, ease of operation, and good outcome [1, 2]. It requires very basic, inexpensive instrumentation, which probably helps make it cost-effective compared with open surgery [3]. Whatever the reasons for the increasing popularity of laparoscopic pyloromyotomy, the approach may be embarked upon safely by those with suitable skills and resources, and is taught easily.

The infant (with nasogastric tube in situ) is placed in the supine position at the foot of the operating table (Fig. 19.1a) or across the table for good ergonomics. Usually, no other specific positioning is required. Occasionally, the pylorus is tucked under the liver, and a small amount of head up-tilt will encourage the rest of the intestines to fall away from the operative field, facilitating access to the pylorus.

A 5-mm supraumbilical incision is made through layers into the abdominal cavity. A 5-mm primary port is inserted and secured (Fig. 19.1b, c). (The supraumbilical incision is preferable to the infraumbilical one, as it may be extended to convert to an open supraumbilical approach if necessary.) Pneumoperitoneum is established to 6 mmHg pressure, which may be increased to 10 mmHg if required and tolerated. The initial flow rate is set between 0.5 and 1 L/min.

Two other working instruments are placed in the right and left sides of the upper abdomen. It is worth noting that the best ergonomics are achieved with the surgeon’s left-handed instrument (grasper) placed laterally in line with the duodenum, whereas the surgeon’s right-handed instrument is best placed medially almost vertically over the pylorus (Fig. 19.2).

Minor oozing is common and not a problem. It is not mandatory to check for leaks if the mucosa has been visualised clearly, with no obvious leaks. If desired, 20–40 mL of air may be injected via the nasogastric tube to distend the stomach. This air then is coaxed into the pylorus with pressure from the instruments, and any leak should be obvious. Leaks may be repaired primarily (via an open or laparoscopic approach, depending on operator’s preference or experience), with or without an omental patch. The wounds are closed with absorbable sutures to the muscle and a subcuticular skin stitch or skin glue. The wound used for the working instruments should be closed before desufflation of the abdomen to help prevent omentum prolapse during closure. The nasogastric tube may be removed at the end of the operation. Feeds may be started and graduated according to local policy. We feed patients after 4–6 h and graduate to full feedings in three or four increments. Infants may be discharged when on full feedings.