Plate 15
###### Figure 4

Pyloroplasty is performed following truncal vagotomy for an obstructed gastric outlet or following resection of the upper stomach or esophagus (see Plate 14). The degree of deformity and the extent of the scarring and inflammation about the pyloric outlet may determine whether use of the stapler is the easiest method of closure of a pyloroplasty.

See Plate 14.

General anesthesia is administered via an endotracheal tube.

The patient is placed in a comfortable, slightly reverse Trendelenburg position.

The usual preparation of the skin of the upper abdomen is completed.

An upper midline incision is made.

The duodenum is mobilized by the Kocher maneuver, and the region of the pylorus is freed of adhesions. Traction sutures (Figure 1, A and B) of 00 silk or absorbable sutures are placed and tied at the superior as well as the inferior margins of the pyloric ring through all layers for anatomic identification. These sutures should be placed to ligate the pyloric vein in order to lessen subsequent bleeding.

A longitudinal incision is made approximately 2 to 3 cm on each side of the pyloric ring through all layers of the anterior wall. Bleeding is controlled by transfixing sutures of fine silk or absorbable sutures. Additional traction sutures (Figure 2, C and D) may be placed through the thickened portion of the pyloric ring in the mid part of the incision on both sides (Figure 2). Traction on sutures C and D widens the formerly narrow lumen of the pylorus. Suture Y (Figure 2) is placed full thickness through both ends of the incision to facilitate closure transversely to the long axis of the pylorotomy. Babcock forceps are used to approximate the gastric and duodenal walls after digital examination in both directions in a search for evidence of obstruction or ulceration.

Approximately three full-thickness sutures (Figure 3, X, Y, and Z) are required to satisfactorily approximate the tissues in readiness for the stapler as the Babcock forceps are removed. The laxity of the tissues may determine the amount of gastric and duodenal wall that extends beyond the linear stapler (TLH 90) stapling instrument, and excess tissue is subsequently removed with the scalpel. The combined thickness of the duodenal and gastric walls determines the height of the staple to be used. The taller 5.5-mm staple is most commonly needed. Additional interrupted sutures are taken ...

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