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22 Atlas of Gastrointestinal Surgery: The Stomach
The Finney pyloroplasty results in a large opening between the stomach and first and second portions of the duode-
num. It is, in fact, a side-to-side anastomosis between the greater curvature of the antrum of the stomach and the medial
aspect of the first and second portions of the duodenum (5, 6).
Finney
5
6
A Jaboulay pyloroplasty is similar to a Finney pyloroplasty, in that it is a side-to-side anastomosis between the greater
curvature of the antrum of the stomach and the medial aspect of the duodenum. However, with the Jaboulay pyloroplas-
ty,the pylorus is not opened, and the anastomosis is performed just to the second portion of the duodenum (7, 8).
Joboulay
7
8
Heineke–Mikulicz Pyloroplasty
Operative Indications
The Heineke–Mikulicz pyloroplasty is perhaps the most frequently performed pyloroplasty. For many years, truncal vago-
tomy with a Heineke–Mikulicz pyloroplasty was the operation of choice for duodenal ulcer disease. It was used not only
in the elective situation but frequently also with a perforated ulcer, whereby the duodenal perforation is incorporated into
the horizontal opening made through the duodenum, pylorus, and stomach in preparation for the pyloroplasty. The
Heineke–Mikulicz pyloroplasty is also used frequently when a vagotomy is performed during an esophagectomy.
Operative Technique
When performing a Heineke–Mikulicz pyloroplasty, I prefer an upper
midline incision.
24 Atlas of Gastrointestinal Surgery: The Stomach
A longitudinal or horizontal opening is made through the proximal first portion
of the duodenum, through the pyloric sphincter, and onto the stomach
(1). Stay sutures are placed superiorly and inferiorly through the
pylorus, and anterior traction helps keep the anterior wall away
from the posterior wall when performing the enterotomy.
The longitudinal opening extends onto the stomach for a
distance equal to that of the duodenal opening. The entire
incision is generally 2 to 5 cm in length.
Transverse
closure
Because narrowing of the pylorus during a pyloroplasty can occur,
Horizontal
opening
1
it is important to close the longitudinal incision in a transverse
fashion with only one layer of sutures (2). The Gambee stitch
2
is ideally suited and is performed by passing the suture full
thickness through the stomach, and then back up through gas-
tric mucosa. The suture is then passed down through duode-
nal mucosa and up through full thickness of the duodenal wall
(insets). It is often easiest to place all sutures before they are
secured. When the Gambee stitches are tied, this ensures an
approximation of the stomach and duodenum with inversion of
the muscosal layer, but avoids inversion of all layers that might lead
to narrowing the pylorus (3).
Gambee stitch
3
Heineke–Mikulicz
pyloroplasty
Pyloromyotomy
Operative Indications
Pyloromyotomy is performed in infants with hypertrophic pyloric stenosis. It is a very effective treatment for this disorder
and perhaps is its most frequent and important indication. Thoracic and alimentary tract surgeons also use it when a vago-
tomy is performed during esophagectomy, and the pyloric sphincter needs to be rendered incompetent.
Operative Technique
Because the duodenum and pylorus are entirely normal and not
involved with peptic ulcer disease, the serosa of the stom-
ach and duodenum, the pyloric muscle, and the muscular
layers of the stomach and duodenum can often be
opened either with the electrocautery or a scalpel, leav-
ing the gastric and duodenal mucosa intact (1).
Pyloromyotomy
1
26 Atlas of Gastrointestinal Surgery: The Stomach
Mucosal
layer
intact
Stay sutures are placed through the pylorus superiorly and
inferiorly, and traction helps separate the muscle layer as it is
being carefully divided with a scalpel or cautery. Each stay suture
is marked with a ligaclip, so that radiologically one can document
long-term separation of the muscle layer (2).
2
To protect against unrecognized leaks, often it is
advisable to tack omentum up around the edges of
the pyloromyotomy (3).
Omentum
3
Finney Pyloroplasty and
Jabouley Modification
Operative Indications
The Finney pyloroplasty is used, as are the other pyloroplasties, to allow gastric emptying after a vagotomy has rendered
the pyloric sphincter inoperative. The Finney pyloroplasty results in a very large opening between the distal stomach and
the proximal duodenum. For a period, many surgeons preferred this type of pyloroplasty over the Heineke-Mikulicz. They
feared that at times the Heineke-Mikulicz pyloroplasty, although destroying the pyloric sphincter, resulted in actual narrow-
ing of the pyloric channel. The Finney pyloroplasty always results in a very large opening between the stomach and the
duodenum. Delayed gastric emptying after the Finney pyloroplasty, however, is surprisingly common. Studies have shown
that the normal progression of peristalsis from the stomach through the duodenum is temporarily disordered by this large
pyloroplasty, resulting in occasional short-term emptying problems.
Operative Technique
The Finney pyloroplasty is generally performed through an upper midline incision.
28 Atlas of Gastrointestinal Surgery: The Stomach
Traction suture
on pylorus
The first and second portions of the duodenum are kocher-
ized. A stay suture is placed through the pyloric sphinc-
ter along the superior aspect of the pyloric channel. A
second stay suture is placed through the greater curva-
ture of the antrum, approximately 5 cm from the
pylorus, and through the second portion of the duode-
num, along its medial aspect, an equal distance from the
pylorus (1). A layer of Lembert sutures is placed using
3-0 silk, approximating the greater curvature of the stom-
Kocherized
duodenum
1
After this outer layer has been placed, the greater
curvature of the stomach, the pyloric channel, and the
medial aspect of the first and second portions of the
ach to the medial aspect of the first and second portions of
the duodenum.
Outer layer of
posterior row
duodenum are opened with the electrocautery (2).
Gastro-
deodenotomy
2
Finney Pyloroplasty 29
The inner layer of the posterior
row of the pyloroplasty is
then run with a continuous
locking suture of 3-0 syn-
thetic absorbable material
(3). The inner layer of the
anterior row of the Finney
pyloroplasty is continued using
a Connell stitch (4).
Divided
pylorus
Inner
layer of
posterior
row
Inner
layer of
anterior
row
3
4
The outer row of the anterior layer of the
pyloroplasty consists of a series of interrupt-
ed 3-0 silk Lembert sutures (5).
Outer
layer of
anterior
row
5
30 Atlas of Gastrointestinal Surgery: The Stomach
To perform a Jabouley modification (which leaves the
pylorus intact) it is necessary to extensively kocherize the
first and second portions of the duodenum, so that the
greater curvature of the stomach can be approximated eas-
ily to the medial aspects of the first and second portions
Inner
layer of
posterior
row
of the duodenum. This procedure actually bypasses the
pylorus and results in a very large opening between the
distal stomach and the proximal first and second portions
of the duodenum (6 and inset).
6
Pylorus
Duodenum
Stomach
Gastrojejunostomy
Operative Indications
Gastrojejunostomy had more extensive indications in the past. It, or pyloroplasty, was used along with truncal vagotomy
for peptic ulcer disease. With the virtual disappearance of duodenal ulcer disease, its usage has greatly decreased. In addi-
tion, gastrojejunostomy was formerly used in patients with inoperable obstructing distal gastric cancers. However, as a
drainage procedure for inoperable gastric cancer, it has been largely ineffective. Today, its most frequent usage is probably
for unresectable periampullary malignancy to avoid late duodenal obstruction. Less frequently, a gastrojejunostomy is used
for unusual disorders such as an annular pancreas or congenital duodenal webs or stenosis.
Operative Technique
Gastrojejunostomy is best performed through an upper midline incision.
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