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Duodenopyloric junction

Serosal incision

FIGURE 33–3

Mucosal layer of

pyloric channel

FIGURE 33–4

Duodenum

FIGURE 33–5

CHAPTER 33 • Pyloromyotomy 349

350 Section IV • The Abdomen

◆ Laparoscopic pyloromyotomy: The patient is placed across the operating table so that sur-

geon and patient are properly aligned. A 3-mm camera port is placed through the umbilicus

with an open technique, and pneumoperitoneum is created to a maximum pressure of

8 mm Hg. A short (22 cm) 3-mm 30-degree telescope is introduced. Two additional 3-mm

ports are placed in the upper quadrants lateral to the rectus muscles (alternatively, the 3-mm

knife and grasper can be placed directly into the abdomen (Figure 33-6). Atraumatic grasp-

ers are used to grasp the duodenum and rotate the pylorus to expose the avascular plane. An

endoscopic pyloromyotomy knife (some surgeons prefer arthroscopy knives) is used to incise

the pyloric serosa over the avascular plane (Figure 33-7). One of the arms of the pyloric

spreader is used to deepen this incision by pushing on the brittle muscle until it gives. This

maneuver is performed in the middle of the incision and never close to the duodenum. The

operation is complete by spreading the muscle until the mucosa prolapses and independent

movement of both pyloric halves can be veriﬁ ed (Figure 33-8). At this time a small amount

of saline is instilled over the pylorus, and the anesthesiologist is asked to insufﬂ ate the

stomach with air to check for leaks. All incisions are inﬁ ltrated with 0.25% bupivacaine and

closed with 6-0 subcuticular, absorbable sutures or Steri-Strips.

Monitor

Surgeon

Assistant

Anesthesiologist

Grasper

Knife

Camera

FIGURE 33–6

CHAPTER 33 • Pyloromyotomy 351

Atraumatic

grasper

Endoscopic pyloromyotomy

knife (or arthroscopy knife)

FIGURE 33–7

Atraumatic

grasper

Endoscopic

pyloric spreader

FIGURE 33–8

352 Section IV • The Abdomen

3. CLOSING

◆ The incision is closed in separate layers with running 5-0 or 6-0 polyglactin sutures. Poste-

rior rectus fascia and peritoneum are closed together; no attempt is made to close the peri-

toneum by itself. The rectus muscle does not need to be reapproximated. After closure of

the anterior rectus fascia, interrupted subcutaneous sutures of 6-0 polyglactin will obliterate

any dead space. The skin is closed with subcuticular 6-0 undyed absorbable monoﬁ lament

sutures and adhesive strips. Before closing, the skin is inﬁ ltrated with 0.25% bupivacaine

without epinephrine at the appropriate dose.

STEP 4: POSTOPERATIVE CARE

◆ Maintenance intravenous ﬂ uids are continued until the patient is tolerating bottle feeds,

which are started 4 to 6 hours after the operation and gradually advanced. It is a good prac-

tice to examine the patient’s abdomen before proceeding with enteral feeds. Many surgeons

use an electrolyte solution such as Pedialyte for the ﬁ rst feed. Some vomiting can be ex-

pected. Most patients are ready for discharge 24 to 48 hours after the procedure.

◆ Complications: The most dreaded complication of this procedure is duodenal perforation,

which is reported in approximately 1% of open pyloromyotomies and between 1% and 2%

of laparoscopic pyloromyotomies. Every effort must be made to identify this complication at

operation, so that the entire pyloromyotomy can be closed with interrupted 4-0 silk sutures

and a new pyloromyotomy performed. The patient is kept on intravenous ﬂ uids, antibiot-

ics, and orogastric suction for 2 to 3 days. A contrast study to conﬁ rm patency of the pylo-

rus and absence of leaks is performed before resuming enteral feeds. Failure to recognize a

perforation results in life-threatening peritonitis and sepsis that mandates immediate resus-

citation, and administration of broad-spectrum intravenous antibiotics, followed by laparot-

omy and washing of the abdominal cavity. The original pyloromyotomy is closed as de-

scribed previously, and a new pyloromyotomy is performed.

◆ Postoperative care is done in a critical care setting, and the need for hemodynamic support

is not unusual. These young patients have an increased incidence of wound infections and

wound dehiscence.

◆ Up to one third of infants after an uncomplicated pyloromyotomy will experience vomiting,

which is typically self-limited. Vomiting is usually managed by holding the next feed and

resuming feeds 6 hours later. If vomiting persists, one must begin to consider the possibility

of an incomplete pyloromyotomy. Although vomiting is not unusual after pyloromyotomy,

abdominal distention is. Abdominal distention should prompt the surgeon to stop feeds and

investigate for duodenal leaks. Wound infections after uncomplicated pyloromyotomy occur

in approximately 2% of cases, and wound dehiscences are quite rare.

STEP 5: PEARLS AND PITFALLS

◆ Avoid incisions that extend into the duodenum. This will surely result in perforation,

because the area of the distal pylorus and proximal duodenum is extremely thin. In fact,

the scoring incision made over the pylorus should stop 2 to 3 mm short of the ring that is

palpated at the distal pylorus. Spreading wide proximal to this area will result in disruption

of the hypertrophic muscle ﬁ bers and release of the constrictive ring.

SELECTED REFERENCES

1. Lobe T, Kumar T: Pyloromyotomy. In Spitz L, Coran AG (eds): Operative Pediatric Surgery, 6th ed.

London, Hodder Arnold, 2006, pp 367-375.

2. Ashcraft K: Atlas of Pediatric Surgery. Philadelphia, Saunders, 1994, pp 85-89.

3. Fujimoto T: Pyloromyotomy. In Najmaldin A, Rothenberg S, Crabbe D, Beasley S (eds): Operative

Endoscopy and Endoscopic Surgery in Infants and Children. New York, Oxford University Press, 2005,

pp 231-234.

CHAPTER 33 • Pyloromyotomy 353

354

STEP 1: SURGICAL ANATOMY

◆ Experience with the anatomy and surgical procedures of the esophagogastric junction are a

prerequisite to a successful gastric bypass operation (Figure 34-1).

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ The standard indications for a bariatric operation include either a body mass index of at

least 40 kg/m

or a body mass index of at least 35 kg/m

with signiﬁ cant associated medical

illness. Potential patients must also have tried multiple dietary, activity, and lifestyle modiﬁ -

cation programs. They should be free of substance abuse and psychologically stable so that

they can make an intelligent decision regarding the risks of the operation and the need to

dramatically alter their lifestyles.

◆ Bariatric operations should not be offered unless a dedicated team is in place for the thorough

preoperative evaluation and close long-term follow-up that are required for every patient.

◆ Patients should receive prophylaxis against wound infection with an intravenous cephalo-

sporin and against venous thrombosis with sequential compression devices and low-

molecular-weight heparin before induction of anesthesia.

◆ General anesthesia is required for this operation. An anesthesia team specially trained and

equipped for the morbidly obese patient is necessary.

◆ Obtaining a controlled airway can sometimes be quite challenging in the morbidly obese patient.

A ﬁ ber-optic scope can be very helpful for an awake intubation. Elective tracheostomy is some-

times a good idea for the massively obese patient, especially one who already has some baseline

respiratory dysfunction where airway control may continue to be a problem postoperatively.

◆ Each incision site is preemptively anesthetized with local anesthetic injection.

CHAPTER

Roux-en-Y Gastric Bypass

(Open and Laparoscopic)

Michael D. Trahan

CHAPTER 34 • Roux-en-Y Gastric Bypass (Open and Laparoscopic)

355

STEP 3: OPERATIVE STEPS

LAPAROSCOPIC

1. INCISIONS

◆ Six small incisions are used for the laparoscopic approach. The incision for the left-sided 12-mm

trocar needs to be approximately 3 cm to later accommodate the circular stapler (Figure 34-2).

Esophagogastric junction

esophageal hiatus

FIGURE 34–1

15 - 20 cm

FIGURE 34–2

356 Section IV • The Abdomen

2. DISSECTION

◆ The 12-mm camera port is placed 15 to 17 cm from the xiphoid process in the midline. A

port with internal visual capability is preferred. The umbilicus is not a useful landmark in

the morbidly obese patient. The peritoneal cavity is inﬂ ated with carbon dioxide to 13 to

15 mm Hg.

◆ The remaining four ports (one 5 mm and one 12 mm in each of the upper abdominal

quadrants as diagrammed) are then placed with internal visualization.

◆ A suture looped under the falciform ligament can often improve visualization and reduce

interference with instrument introduction (Figure 34-3).

◆ The omentum is divided in the midline all the way to and for a short distance along the

transverse colon using the ultrasonic shears. This will allow placement of the Roux limb

anterior to the colon and stomach with less tension. Adhesions to the abdominal wall may

need to be divided ﬁ rst (Figure 34-4).

◆ The omentum is placed above the transverse colon, which is then retracted superiorly by

the assistant’s grasping of the transverse mesocolon (Figure 34-5).

Sutured loop

under falciform

ligament

Hepatogastric

ligament

vagus nerve

FIGURE 34–3

Creating omental window

FIGURE 34–4

Jejunum

Ligament of Treitz

Omental window

FIGURE 34–5

CHAPTER 34 • Roux-en-Y Gastric Bypass (Open and Laparoscopic)

357

358 Section IV • The Abdomen

◆ The ligament of Treitz is identiﬁ ed and followed until the mesentery lengthens (usually

30 to 40 cm). The jejunum is divided transversely with a linear cutting stapler loaded with

2.5-mm staples. A 45-mm stapler length is adequate (Figure 34-6).

◆ The mesentery of the distal aspect of the divided jejunum is incised next to the bowel wall

to provide additional mobility of the Roux limb. Any ischemic area created by this maneu-

ver will be trimmed during one of the ﬁ nal steps (Figure 34-7).

Dividing jejunum

approximately 30 cm

distal to ligament of Treitz

FIGURE 34–6

Incising mesentery

several cm along Roux limb

Roux limb

of jejunum

FIGURE 34–7