OT notes · Paediatric Surgery

Ramstedt pyloromyotomy

Usual anaesthesia
General anaesthesia, with the stomach emptied through a nasogastric tube first
Position
Supine
Setting
urgent

Operative note template for open Ramstedt pyloromyotomy for infantile hypertrophic pyloric stenosis, with a filled example for a 4-week-old boy operated through a supraumbilical incision after correction of alkalosis.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • mucosal perforation needing repair, a longer fast and a nasogastric tube
  • incomplete myotomy with continued vomiting and a second operation
  • some vomiting after feeds in the first days
  • wound infection
  • bleeding from the cut edges
  • chest infection

Pre-operative details for this operation

  1. Age, weight and birth weightage in days or weeks, weight in kg today
  2. How the diagnosis was madePalpable olive on test feedUltrasoundContrast studyfor ultrasound: muscle thickness and channel length in mm
  3. Dehydration and correctiondegree of dehydration, fluids given (type, mL/kg), hours of resuscitation
  4. Pre-op electrolytes and blood gasNa, K, Cl, HCO3 (or total CO2), pH, time of the sample; must be near normal before surgery
  5. Urine output establishedYes
  6. Nasogastric tubesize, on free drainage, volume aspirated before induction
  7. Consentgiven by parent or guardian: name, relation, language

Anaesthesia and position

  1. AnaesthesiaGeneral
  2. PositionSupine
  3. Temperature carewarming used

Operative findings

  1. Pyloric tumoursize in cm, firm, pale grey
  2. Distal limitpyloric vein of Mayo identified
  3. StomachDilated, thick-walledNormal
  4. Myotomylength in cm, two halves moving independently, mucosa bulging along the full length
  5. Air leak testNo leakMucosal perforation: site
  6. Other findingsmalrotation, hernia, other anomalies

Procedure (steps)

  1. Painting and drapingantiseptic used
  2. IncisionSupraumbilical curvilinear (Tan-Bianchi)Right upper quadrant transverseLaparoscopic (3 ports)length in cm
  3. Entry into peritoneumlinea alba opened upward, umbilical vein pushed aside / muscles cut or split
  4. Stomach deliveredgreater curve held with non-traumatic forceps or moist swab; pylorus not grasped
  5. Pyloric tumour delivered into the woundby rocking traction; incision extended if needed
  6. Serosal incisionavascular anterior surface, from just short of the vein of Mayo onto the antrum, length in cm
  7. Muscle split to submucosaback of scalpel handle, then spreader (Benson / Dennis Browne), especially careful at the duodenal end
  8. Adequacy checkedtwo halves move independently
  9. Leak testair through the nasogastric tube (volume), milked into the duodenum, swab checked for bile
  10. Perforation repair (if any)Not neededDirect suture: material and sizeMyotomy closed and redone on the other sideOmental patch
  11. Pylorus returned to the abdomen, bleeding from the edges checked

Closure, drains and dressing

  1. Peritoneum, muscle and fasciainterrupted absorbable (polyglycolic acid or polydioxanone), size
  2. Subcutaneous tissuecontinuous 4/0 absorbable
  3. SkinSubcuticular 5/0 absorbableTissue glue
  4. Local anaesthetic to woundbupivacaine 0.25%, volume in ml and ml/kg
  5. Nasogastric tube at the endRemovedLeft in (perforation repaired)

Specimens and implants

  1. SpecimenNone (no tissue removed)

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Monitoringheart rate, SpO2, apnoea, temperature
  2. IV fluidstype and mL/kg/day until full feeds
  3. Feeding planfirst feed: volume and time; when to go to ad libitum feeds
  4. If mucosa was repairednasogastric tube, nil by mouth 24 hours, IV antibiotics 48 hours
  5. Vomitinga few vomits are expected; record amount and character; escalate if persistent
  6. Analgesiadrug and weight-based dose
  7. Electrolytesrepeat if abnormal before surgery
  8. Woundcheck umbilical wound for infection
  9. Discharge and follow-upwhen on full feeds; OPD date

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Baby of Mrs. P.D. (male), 4 weeks, weight 3.6 kg, projectile non-bilious vomiting for 6 days, palpable olive on test feed. Admitted with hypochloraemic metabolic alkalosis.

Case details

Date: 22/07/2026. Urgent (next available list after correction). Start 10:05, end 10:40.

Surgeon: Dr A. (3rd-year resident, MCh Paediatric Surgery). Assistant: Dr B. Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Infantile hypertrophic pyloric stenosis. Olive palpable. Ultrasound: muscle thickness 5 mm, channel length 19 mm.

On admission: Na 131, K 2.9, Cl 86 mmol/L, HCO3 34 mmol/L. Given NS 20 ml/kg (72 ml) over 1 hour, then 5% dextrose in 0.45% saline with KCl 20 mmol/L at 150 ml/kg/day once passing urine. Nasogastric losses replaced ml for ml with NS containing KCl 20 mmol/L.

After 36 hours: Na 137, K 4.0, Cl 102 mmol/L, HCO3 25 mmol/L. Passing urine well.

Nasogastric tube 8 Fr on free drainage, aspirated before induction.

Consent: procedure-specific consent taken from the father, Mr. P.D., in Telugu, including the risk of perforation and incomplete myotomy.

WHO checklist sign in and time out done. Prophylactic antibiotic given at induction, drug and weight-based dose recorded on the anaesthesia chart.

Anaesthesia and position

General anaesthesia. Supine on a warming mattress. Abdomen painted with povidone-iodine and draped, umbilicus cleaned.

Procedure

2 cm curvilinear incision in the upper fold of the umbilicus. Linea alba cleared and opened upward for 2 cm, umbilical vein pushed aside, peritoneum opened.

Greater curve of the stomach held with non-traumatic forceps and a moist swab. Pyloric tumour delivered by gentle rocking traction without grasping it.

Findings: firm pale pyloric tumour about 2 x 1.5 cm. Vein of Mayo clearly seen. Stomach dilated and thick-walled. No other abnormality seen in the wound.

Serosa incised along the avascular anterior surface for 2.5 cm, from just short of the vein of Mayo onto the antrum.

Muscle split down to submucosa with the back of the scalpel handle, then widened with a Benson spreader, taking care at the duodenal end. Mucosa bulging along the whole length. Two halves moving independently.

20 ml of air pushed through the nasogastric tube and milked into the duodenum. No air leak, no bile on the swab.

Mild ooze from the muscle edges, stopped after the pylorus was returned to the abdomen.

Closure

Peritoneum and linea alba closed with interrupted polyglycolic acid sutures. Subcutaneous tissue with continuous polyglycolic acid 4/0. Skin with subcuticular polyglycolic acid 5/0.

Bupivacaine 0.25%, 0.9 ml (0.25 ml/kg) infiltrated into the wound.

Nasogastric tube aspirated and removed at the end.

End of procedure

Blood loss about 5 ml. No complications. No mucosal perforation.

Mop, needle and instrument count correct. No specimen.

Awake in OT, crying, pink. HR 145/min, SpO2 98% on room air. Shifted to the paediatric surgery ward with apnoea monitor.

Post-op orders

HR, SpO2 and apnoea monitoring overnight. Temperature 4-hourly.

IV 5% dextrose in 0.45% saline with KCl 20 mmol/L at 150 ml/kg/day until feeding well.

First feed: 15 ml expressed breast milk when awake. If kept down, breastfeed on demand from 1 hour later. Reduce IV fluid as feeds increase.

Record every vomit. A few small vomits are expected; inform if repeated or large.

Oral paracetamol by weight as charted by the anaesthetist.

Expected discharge when on full feeds. Review in OPD after 1 week.

Signature

Dr A., MCh resident (year 3), Paediatric Surgery. Reg. no. ________. 22/07/2026, 10:55.

Must document for this operation

  • Electrolytes and blood gas before surgery, with the time taken. Pyloromyotomy is never an emergency: surgery waits until dehydration and alkalosis are corrected, and these values are the proof that they were.
  • Weight on the day of surgery. Every fluid rate and drug dose is per kg, and the weight on admission may be lower than the birth weight.
  • Length of the myotomy and that the two halves move independently. Incomplete myotomy, usually short at the gastric end, is the reason for a repeat operation.
  • Result of the air leak test. A missed duodenal perforation causes peritonitis, and a recorded negative test is the evidence that it was checked.
  • Any perforation, where it was, and how it was closed. It changes the feeding plan, antibiotics and nasogastric care, and the ward team must know.
  • Feeding plan written in the note. Nurses and parents follow it, and wrong early feeding is a common cause of confusion over post-operative vomiting.

Common mistakes in these notes

  • Not recording the pre-op electrolytes and the time of the sample.
  • Writing 'pyloromyotomy done' with no length and no check of adequacy.
  • Leaving out the air leak test.
  • Not writing the weight, so doses in the orders cannot be checked.
  • Treating early vomiting as failure without writing what the operation found and did.

Indian practice and paperwork

  • Consent must be in a language the parent understands, and taken by the person who will do the procedure. (NABH 5th ed., PRE.4(c) and (e))
  • The post-operative care, here the feeding plan, must follow a written plan, and the operative note must be written before the baby leaves recovery. (NABH 5th ed., COP.14(e) and (f))
  • Paediatric records are advised to be kept until the child reaches majority, as there is no fixed Indian retention rule. (Thomas J. Indian J Urol 2009;25(3):384-8)

Sources

  • Davenport M, Geiger JD, eds. Operative Pediatric Surgery (Rob & Smith's Operative Surgery). 8th ed. CRC Press; 2021, Ch 32, Pyloromyotomy (Hall NJ), e-book PDF pp. 819-834.
  • Sriram Bhat M. SRB's Surgical Operations: Text and Atlas. Jaypee; 2014, Ch 20, Surgery of stomach and duodenum: Ramstedt's pyloromyotomy, pp. 691-692.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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