Pyloroplasty

Fig. 7.1

Port setup for laparoscopic pyloroplasty

The Heineke-Mikulicz technique is the most straightforward approach for pyloroplasty. Because the pylorus itself is not inflamed in patients with gastroparesis, there is no need to employ other techniques such as a Jaboulay pyloroplasty. The pylorus can often be identified by visualizing the prepyloric vein of Mayo. If there is any doubt about the location of the pylorus, endoscopic visualization can be useful. After proper identification, the pylorus is grasped at its proximal border, at a point along both the lesser curve and the greater curve. A 5–6 cm longitudinal incision is made along the anterior gastroduodenal junction with an ultrasonic shears. Care must be taken to avoid damage to the back wall of the stomach during this maneuver, and elevation of the pylorus by both the assistant and the surgeon’s left hand will help prevent this. The defect is inspected, and both gastric and duodenal extension are assured (Fig. 7.2). The location of the pyloromyotomy can be fully verified once the gastric and duodenal mucosa is seen as the pylorus appears as a divided ring within the incision.

../images/470130_1_En_7_Chapter/470130_1_En_7_Fig2_HTML.png — Fig. 7.2

Heineke-Mikulicz pyloroplasty , with the longitudinal 5–6 cm incision (a) with adequate intraluminal view of both stomach and duodenum (b) and transverse closure (c)

I often employ a stitch through the superior aspect of the pylorus itself, which is retracted cephalad after passing it transfascially. This helps line up the edges of the pyloroplasty for ease in defect closure. The defect is then closed transversely with a running long-acting absorbable suture in a single layer. This can be done laparoscopically, although some prefer to use the robot for ease of suturing. Care must be taken to avoid incorporating the back wall of the stomach or duodenum in the closure. This particular complication is typically discovered during endoscopic leak test, and immediate revision of the suture line is rarely required but can be very effective.

After the suture line is complete, endoscopic leak test with air or methylene blue can identify any weakness of the suture line. An omental patch can be used to reinforce the suture line if desired.

Postoperative Care

All patients are typically discharged after 23 hours’ observation. Upper GI contrast study on postoperative day 1 can evaluate for leak and passage of contrast through the pyloroplasty, though this is not universally performed. We routinely send patients home on a pureed diet for two weeks. A proton pump inhibitor is given for four weeks following surgery to improve suture line healing. Many groups perform follow-up testing, including a gastric emptying study at three months to document improvement in gastric emptying. Follow-up endoscopy is not required but if performed will demonstrate a definite widening of the pylorus with easy passage into the duodenum (Fig. 7.3).