Pyloroplasty (Heineke–Mikulicz)

Procedure Snapshot

• Indication: Pyloric stenosis from ulcer scarring, vagotomy adjunct, or delayed gastric emptying.
• Expected duration: ___
• Special instruments: Fine retractors, stay sutures, 3-0 Vicryl or PDS, needle drivers.

Step Workflow

1. Supine, midline or RUQ incision.
2. Expose duodenum (Kocher maneuver if needed).
3. Longitudinal incision across pylorus into stomach & duodenum (~4 cm).
4. Close transversely in two layers (inner mucosa, outer seromuscular).
5. Test for leak with saline.

Key Pimp Questions

• Q: Purpose of transverse closure?
  A: Widens outlet by converting longitudinal to transverse axis.
• Q: When combined with vagotomy?
  A: To ensure gastric emptying post-truncal vagotomy (PMID 32349102).

Critical Anatomy

• Landmarks: Pylorus, GDA, right gastric & gastroepiploic arteries.
• Danger zones: Posterior duodenal wall (GDA), CBD.

Informed Consent Highlights

• Bleeding __, leak __, delayed emptying ___.

Post-op Considerations

• NGT until flatus; gradual diet advance. PPI if ulcer cause.

References

• Chassin’s, Foregut chapter. Clinical Scenarios, Stomach section.
• Ferguson 2020 (PMID 32349102).