Pyloroplasty Technique

Updated: Oct 14, 2015
  • Author: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS; Chief Editor: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS  more...
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Technique

Approach Considerations

A midline incision is most commonly used to perform pyloroplasty. This incision is quick and bloodless; moreover, it may be extended between the xiphisternum and costal cartilage, if required. The falciform ligament is divided between ligatures. The second part of the duodenum is mobilized via kocherization, with the peritoneum incised on its lateral aspect.

Heineke-Mikulicz pyloroplasty is not suitable for scarred/fibrosed/indurated pyloroduodenum in pyloric stenosis; Jaboulay pyloroplasty may be performed in such cases.

Pyloroplasty can also be performed laparoscopically; laparoscopy-assisted transoral endoscopic circular stapled pyloroplasty has also been described. [5]

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Heineke-Mikulicz Pyloroplasty

Two 3-0 stay sutures are placed, one above (superior) and the other below (inferior) at the level of the pylorus (not the level of the duodenum, where the wall is thin).

A 5-cm-long full-thickness antroduodenal transverse incision is started in the prepyloric antrum across the pylorus into the first part of the duodenum (2-3 cm on the antrum and 2-3 cm on the duodenum). This incision can be performed with electrocautery at low wattage for better hemostasis.

In bleeding, the duodenal ulcer is usually seen on the posterior wall of the first part of the duodenum.

For perforation, the incision is taken through the perforation in the anterior wall of the first part of the duodenum. There is no need to excise the perforation, because duodenal ulcers are almost never malignant. (This may be contrasted with gastric ulcer perforation, in which the ulcer should be excised or biopsied because gastric ulcers can be malignant.)

The longitudinal incision is stretched into a diamond shape by applying traction on the stay sutures, then closed transversely with a single row of interrupted sutures. In the Weinberg modification of the original Heineke-Mikulicz pyloroplasty, multiple rows of sutures are used. Gambee inverting sutures may be used instead of simple sutures. Long-acting 3-0 synthetic absorbable suture material is used, and bites are taken 2-3 mm apart and 2-3 mm from the edge. All sutures are taken and held in mosquito forceps and then tied.

A Gambee suture starts outside; it goes from serosa (out) through full thickness to mucosa (in) and then from mucosa to submucosa on the same side. The suture then goes from submucosa to mucosa on the opposite wall and then from mucosa (in) through full thickness to serosa (out). Correct placement of this sutures ensures inversion of mucosa.

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Jaboulay Pyloroplasty

A Jaboulay pyloroplasty is a side-to-side gastroduodenostomy between the anterior surfaces of the stomach and duodenum; the pylorus is not incised.

The greater curvature of the prepyloric antrum is attached to the medial wall of the adjacent duodenum via interrupted seromuscular sutures. Two separate incisions are made, one through the prepyloric antrum and the other through the first part of the duodenum. The posterior inner layer of the gastroduodenal anastomosis is completed with a continuous full-thickness suture; the anterior inner layer is completed with a continuous inverting Connell (loop on mucosa) suture. Finally, anterior seromuscular interrupted sutures are taken. The anastomosis can also be performed in a single layer.

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Finney Pyloroplasty

Finney pyloroplasty, a procedure that is rarely performed today, is a side-to-side gastroduodenostomy between the anterior surfaces of the stomach and duodenum. It differs from the Jaboulay pyloroplasty in that the pylorus is incised.

The greater curvature of prepyloric antrum is attached to the medial wall of the adjacent duodenum via interrupted seromuscular sutures. A single inverted U- or V-shaped incision is made though the prepyloric antrum, the pylorus, and the first part of the duodenum. The posterior inner layer of the gastroduodenal anastomosis is completed with a continuous full-thickness suture; the anterior inner layer is completed with a continuous inverting Connell (loop on mucosa) suture. Finally, anterior seromuscular interrupted sutures are taken. The anastomosis can also be performed in a single layer.

Pyloroplasty has also been performed with a circular stapler [6] and with a linear stapler [7] .

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Pyloromyotomy

Pyloromyotomy (the Ramstedt operation) is most commonly performed for congenital hypertrophic pyloric stenosis.

The incision starts about 1 cm proximal to pylorus and runs across the “tumor” to a point about 1 cm distal to the pylorus on the first part of the duodenum. Muscle fibers are split with fine-tipped curved mosquito artery forceps until the mucosa is reached, which then bulges through the defect in muscle; the mucosa is not opened.

The suture line of the pyloroplasty/pyloromyotomy can be covered with omentum or a vascularized flap (based on epiploic/omental vessels) of omentum to decrease the risk of anastomotic leakage.

A per-oral endoscopic approach to pyloromyotomy has been described; early human results suggest that it may be a promising treatment for gastroparesis. [8]

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Pyloric Dilatation

In pyloric dilatation, a small gastrotomy is made on the anterior wall of the stomach, midway between the lesser and greater curvatures of the stomach, about 3-4 cm proximal to the pylorus. The pylorus can be dilated with a finger, a balloon (45 psi for 1 minute), or a Tubb or Hegar dilator [9] . The gastrotomy is closed in two layers: inner full-thickness and outer seromuscular.

Pyloric dilatation can also be performed nonsurgically (endoscopically and radiologically).

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Complications

During pyloromyotomy, duodenal mucosa may be opened unintentionally. However, the stomach wall is thick, and gastric mucosa is not commonly opened.

When performed in two layers, pyloroplasty can result in excessive inversion and narrowing, which may manifest as gastric outlet obstruction.

The following are other potential postoperative complications:

  • Anastomotic leakage
  • Dumping (due to pyloric disruption)
  • Bile reflux and vomiting (though less frequently than is the case after gastrojejunostomy)
  • Diarrhea (due to associated vagotomy)
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