Step 1: Clinical Anatomy
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Jaboulay “pyloroplasty” is actually a gastroduodenostomy between the antrum of the stomach and the duodenum. The pylorus is not technically incised. ( Figure 14-1 )
Figure 14-1
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This operation results in a large opening between the distal stomach and duodenum and avoids the inflammatory process in the pyloric area.
Step 2: Preoperative Considerations
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Jaboulay gastroduodenostomy combined with a truncal vagotomy is best suited in the treatment of gastric-outlet obstruction from a duodenal ulcer. The Jaboulay gastroduodenostomy effectively improves gastric emptying.
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The Jaboulay gastroduodenostomy has the advantages of relatively easy exposure and dissection. The technique avoids the dissection of inflamed or friable peripyloric tissue. There is no need to oversew or disturb the ulcer base if no active bleeding has occurred.
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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A Kocher maneuver is performed by mobilizing the lateral aspect of the second portion of the duodenum. The first two fingers of the left hand can be used to bluntly open up the plane behind the duodenum. A scissor motion can help to open up the retroperitoneal and retropancreatic space.
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The antrum of the stomach and the duodenum are aligned by placing a traction suture just proximal to the pylorus along the greater curve of the stomach. This site is approximated to an area of the duodenum just distal to scarred pylorus. A second traction suture is placed more proximal on the stomach along the greater curve and more distal on the duodenum approximately 7 to 9 cm from the first suture. ( Figure 14-2 )
