Chapter 16 Vagotomy and Pyloroplasty
INTRODUCTION
Pyloroplasty was first performed by Heineke in 1886 for a patient with an obstructing pyloric mass.1 Less than 1 year later, Mikulicz2 described a similar operation for the treatment of a bleeding duodenal ulcer. Because of the temporal relationship of these two reports, the technique of opening the pylorus longitudinally and closing it transversely is known as the Heineke-Mikulicz pyloroplasty.3 Over the next several decades, other methods of gastric drainage were developed. In 1892, the Jaboulay pylorplasty, a misnomer because it is actually a gastroduodenostmy, was described for the treatment of an obstructing pyloric mass.4,5 In 1902, Finney6 reported a method of pyloroplasty that also incorporated a gastroduodenostomy.3 It was not until 1943 that Dragstedt sectioned the vagus nerves just above the diaphragm to control hyperacidity and popularized truncal vagotomy in conjunction with pyloroplasty.7 Although described several decades ago, the Heineke-Mikulicz pyloroplasty and Finney pyloroplasty continue to be two of the most common techniques performed by surgeons today for the treatment of peptic ulcer disease.
Recurrence rates after truncal vagotomy are unaffected by the type of pylorplasty performed.8,9 The Heineke-Mikulicz pyloroplasty is recommended for routine cases because of its ease and simplicity.10 However, in patients with a very tight pyloric obstruction, this approach can be difficult to perform.11 In cases in which the stomach lays primarily in the longitudinal axis (i.e., is J-shaped), the Finney pyloroplasty is the preferred technique.3,5 The Finney pyloroplasty is also recommended in patients with ulcers in the second portion of the duodenum or when chronic inflammation has displaced the pylorus and duodenum under the liver.10 In cases of severe scarring and fibrosis of the pylorus, the Jaboulay gastroduodenostomy is an alternative for gastric drainage.5
Vagotomy and pyloroplasty is considered a relatively quick and simple operation with good postoperative results.12 Long-term ulcer recurrence rates range from 5% to 15%.3,7,8,10,13,14 Complications, although rare, do occur.13 Chan and coworkers15 reported a less than 1% mortality rate. Skellenger and colleagues3 reported a major operative complication rate of 5%, which included serious complications such as esophageal perforation, splenic rupture, and anastomotic leak. Although vagotomy and pyloroplasty has the potential to be mastered in a relatively short period of time, its success is directly related to the training, experience, and attention to detail of the operating surgeon.12,13
Vagotomy and pyloroplasty can be approached laparoscopically as well.16,17 The laparoscopic technique closely duplicates the open approach and, therefore, is not discussed here. Complications of general laparoscopy are discussed in Section I, Chapter 8, Laparoscopic Surgery.
OPERATIVE STEPS
Heineke-Mikulicz Pyloroplasty5,18,21
Finney Pyloroplasty5,18,21
OPERATIVE PROCEDURE
Mobilization of the Left Lobe of the Liver
Encircling the Esophagus and Identification of the Vagus Nerves
Esophageal Perforation
• Consequence
• Repair
![](https://freepngimg.com/download/social_media/63059-media-icons-telegram-twitter-blog-computer-social.png)
Stay updated, free articles. Join our Telegram channel
![](https://clinicalpub.com/wp-content/uploads/2023/09/256.png)
Full access? Get Clinical Tree
![](https://videdental.com/wp-content/uploads/2023/09/appstore.png)
![](https://videdental.com/wp-content/uploads/2023/09/google-play.png)
![](https://clinicalpub.com/wp-content/uploads/2023/09/banner1.png)