Step 1: Surgical Anatomy
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The Finney pyloroplasty is preferred when a longer incision on the duodenum is required to control bleeding. A fibrotic duodenum may require closure with a Finney pyloroplasty as well.
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When scarring of the pylorus and duodenal bulb prohibits a tension-free patulous Heineke-Mikulicz pyloroplasty, a Finney-type closure can be used. The Finney pyloroplasty is essentially a side-to-side gastroduodenostomy.
Step 2: Preoperative Considerations
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In the acute setting, a nasogastric tube should be placed to confirm upper gastrointestinal bleeding and to prevent aspiration. Upper endoscopy is helpful for diagnosis and potentially allows for endoscopic control of bleeding, obviating the need for an operation.
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In chronic patients with peptic ulcer disease, nutritional status should be optimized by enteral or parenteral means. It can take several days to correct nutrition and electrolytes in the patient with long-term gastric-outlet obstruction.
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Patients requiring an operation for long-term outlet obstruction often have dilatation and elongation of the stomach. A Finney pyloroplasty is preferred in this instance because it provides better drainage of the stomach.
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Preoperative preparation consists of deep vein thrombosis prophylaxis and antibiotics. Many of these patients have been on long-term proton-pump inhibitor therapy, thereby altering the acidity and bacterial flora of the gastric lumen. Preoperative antibiotics should consist of first- or second-generation cephalosporins.
Step 3: Operative Steps
1.
Incision
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An upper midline incision provides adequate exposure for most gastric procedures. In the emergent setting, this approach provides the quickest and driest entry into the abdominal cavity. Alternatively, a left subcostal incision may be used; however, this is more painful and results in a higher rate of hernia formation.
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The upper midline incision may be extended superiorly to the xiphoid process for exposure of the esophageal hiatus. The cartilaginous xiphoid should not be cauterized to avoid heterotopic ossification.
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Once the peritoneum is entered, the falciform ligament should be divided to allow for upward retraction of the left lateral lobe of the liver.
2.
Dissection
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Unlike the Heineke-Mikulicz pyloroplasty, the incision for the Finney pyloroplasty is closer to the greater curvature on the stomach side and onto the medial aspect of the duodenum on the pancreatic side. This incision location relieves tension on the anterior suture line. ( Figure 13-1 )
