Pyloroplasty
What the Examiner Expects
Widening of the pyloric channel to facilitate gastric emptying, most commonly performed as a companion drainage procedure to truncal vagotomy. The Heineke-Mikulicz technique is most common: a longitudinal full-thickness incision is made across the pylorus (identified by the vein of Mayo) and closed transversely in a single layer, effectively widening the channel. The Finney pyloroplasty creates a larger opening via a side-to-side gastroduodenostomy. The examiner expects you to know that pyloroplasty is mandatory with truncal vagotomy but not with highly selective vagotomy, and to understand the technical steps.
Key Examiner Focus Points
- Heineke-Mikulicz: longitudinal incision across pylorus, closed transversely
- Finney: side-to-side gastroduodenostomy
- Required as drainage procedure after truncal vagotomy
- Also used for gastric outlet obstruction from chronic scarring
- Know the landmarks — pyloric vein of Mayo marks the pylorus
Common Curveballs
Severe scarring and inflammation at the pylorus make pyloroplasty unsafe
Perform a gastrojejunostomy as the drainage procedure instead. This bypasses the scarred pylorus. A retrocolic, isoperistaltic gastrojejunostomy avoids the diseased area entirely.
Postop gastroparesis despite a technically adequate pyloroplasty
Assess for other causes (medications, electrolyte imbalances, diabetes). Supportive care with prokinetics (metoclopramide, erythromycin). Most resolves with time. If persistent, evaluate with gastric emptying study.