Vagotomy and Pyloroplasty

Chapter 16 Vagotomy and Pyloroplasty



Tamica White, MD, Patrick G. Jackson, MD



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.



INDICATIONS



• Obstructing gastric and/or duodenal ulcer

• Bleeding gastric and/or duodenal ulcer

• Perforated gastric and/or duodenal ulcer

• Gastric replacement after esophagectomy

• Pyloric stenosis (pyloroplasty only)


OPERATIVE STEPS



Vagotomy18–20



Step 1 Mobilization of the left lobe of the liver (if necessary)

Step 2 Incision of the peritoneal reflection over the distal esophagus

Step 3 Encirclement and placement of a Penrose drain around the esophagus

Step 4 Exposure and resection of a segment of the anterior vagus nerve

Step 5 Anterolateral traction on the esophagus to expose the posterior vagus nerve

Step 6 Division and resection of a segment of the posterior vagus nerve


Heineke-Mikulicz Pyloroplasty5,18,21



Step 1 Kocher maneuver

Step 2 Placement of stay sutures superiorly and inferiorly to the planned incision site

Step 3 Longitudinal incision anteriorly through all layers of the pylorus extending onto the stomach and duodenum

Step 4 Transverse closure of the incision

Step 5 Placement of an omental patch over the pyloroplasty (optional)


Finney Pyloroplasty5,18,21



Step 1 Kocher maneuver

Step 2 Placement of stay sutures (at the superior margin of the pyloric ring and 10 cm proximal and distal to the pylorus on the stomach and duodenum)

Step 3 Interrupted row of posterior seromuscular sutures through the apposing walls of the stomach and duodenum

Step 4 U-shaped incision into the lumen of the stomach extending to the duodenum transecting the pylorus

Step 5 Running closure of the posterior and anterior inner layers between the stomach and the duodenum

Step 6 Interrupted row of anterior seromuscular sutures

Step 7 Placement of an omental patch over the pyloroplasty (optional)


Jaboulay Pyloroplasty5,21



Step 1 Kocher maneuver

Step 2 Placement of traction sutures to approximate the duodenal and gastric walls

Step 3 Interrupted row of seromuscular sutures through the apposing walls of the stomach and duodenum

Step 4 Incisions into the lumen of the stomach and duodenum leaving the pylorus intact

Step 5 Running closure of posterior and anterior inner layers between the stomach and the duodenum

Step 6 Interrupted row of anterior seromuscular sutures

Step 7 Placement of an omental patch over the pyloroplasty (optional)


OPERATIVE PROCEDURE



Mobilization of the Left Lobe of the Liver



Injury to the Phrenic Vein


In some cases, the left lobe of the liver must be taken down in order to provide exposure to the gastroesophageal junction. Care must be taken not to enter the rather large phrenic vein located within the diaphragm in this region.21



• Consequence



Bleeding.

Grade 2/3 complication


• Repair



The vein can be ligated with impunity once identified.


• Prevention



The phrenic vein should be anticipated during the dissection to avoid transecting it unexpectedly. In those patients with a particularly turgid or fibrotic left lobe, mobilization is futile because the lobe will be extremely difficult to fold.22


Encircling the Esophagus and Identification of the Vagus Nerves



Esophageal Perforation



• Consequence



Intra-abdominal leak with peritonitis. Esophageal perforation during vagotomy is a rare complication with an incidence of less than 1%22–24 (Fig. 16-1). However, the morbidity of this complication is high, particularly if it goes unrecognized during the original procedure.25 Skellenger and colleagues3 reported that esophageal perforation during vagotomy is usually the result of blind finger dissection of the esophagus. Factors contributing to esophageal perforation include the obese, patients with friable inflamed tissue, portal hypertension, or previous surgery in that region.22

Grade 3/4/5 complication

image

Figure 16-1 Encircling esophagus at hiatus.



• Repair



Esophageal perforation identified intraoperatively should be repaired primarily in layers. Postoperative esophageal leak can be managed with nasogastric tube decompression and antibiotics when appropriate. Larger postoperative leaks with evidence of peritonitis and hemodynamic instability require reoperation.

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Jun 21, 2017 | Posted by in GENERAL SURGERY | Comments Off on Vagotomy and Pyloroplasty

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