Gastric 6

Surgery

A Pyloroplasty

laparoscopic Heineke–Mikulicz pyloroplasty is performed in the same way as an open surgery. The most commonly encountered difficulty is recognition of the pyloric muscle through the scope.

For this reason it is advisable to note some of the landmarks that can be sought out, such as the pyloric vein of Mayo running on the muscle’s surface and the change in diameter between the distal end of the stomach, the pyloric area, and the postpyloric region. It is usually possible to identify the pylorus using these anatomical features; however, in case of difficulty, the procedure can begin and once underway, a laparoscope can be inserted into the duodenum from the gastric side of the pyloroplasty, permitting recognition of the pyloric muscle by the change in caliber. Even then it can sometimes be difficult to identify the pylorus. In such cases, one can remove one trocar, insert a finger into the opening after partially deflating the abdomen and locate the pylorus by palpation (Fig. 6.1).

When the pyloroplasty has been created longitudinally, it is possible to suture it transversely exactly as in open surgery using interrupted stitches of 3–0 Prolene (the 4–0 suture used in open surgery is a little too thin and the risk of breaking the suture is greater). The 3–0 suture will give adequate strength for intracorporeal or extracorporal knot-tying; both are possible. The author advises buttressing the pyloroplasty with a small omental patch as an extra safety measure (Fig. 6.2).

N. Katkhouda, Advanced Laparoscopic Surgery,

DOI: 10.1007/978-3-540-74843-4_6, © Springer-Verlag Berlin Heidelberg 2011

Fig. 6.1  A  finger  inserted  in  one  of  the  port  openings  to  palpate  the  pyloric  muscle  (“fingeroscopy”)

Fig. 6.2 Suturing the pyloroplasty and omental patch