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INDICATIONS

Laparoscopic pyloroplasty is most frequently performed as an adjunct to laparoscopic Nissen fundoplication for patients with gastroesophageal reflux and delayed gastric emptying, and may be used in conjunction with laparoscopic esophagectomy. Most frequently, pyloroplasty is indicated in esophagectomy, but may be indicated in iatrogenic gastric emptying disorders, where a previous operation has damaged the vagus nerve and created impaired gastric emptying. Because Nissen fundoplication, by itself, improves gastric emptying, pyloroplasty is reserved for those with profound emptying disorders manifest by residual food in the stomach on endoscopy and/or solid phase emptying that is twice the upper limit of normal (T½ ≥ 150 min). Other indications for pyloroplasty include gastroparesis outside the setting of fundoplication, or in a patient who has a very functional Nissen fundoplication but evidence of profound gastroparesis. For patients undergoing laparoscopic esophagectomy, pyloroplasty will improve gastric conduit emptying; however, it may accelerate gastric emptying sufficiently to create dumping and diarrhea, and may increase bile reflux.

PREOPERATIVE PREPARATION

Patients with symptoms of delayed gastric emptying (e.g., bloating, early satiety, postprandial upper abdominal pain, vomiting) deserve evaluation with a 4-hour solid (or dual) phase nuclear medicine gastric emptying study. In addition, upper endoscopy should be performed on any patient being evaluated for pyloroplasty. Food remaining in the stomach after an overnight fast is not unusual in patients with gastroparesis. Anatomic abnormalities of the pylorus such as gastric outlet obstruction from peptic ulcer disease must be ruled out, as a pyloroplasty in the presence of chronic or acute inflammation may lead to serious complications.

ANESTHESIA

General anesthesia is used. A preoperative antibiotic is administered. For isolated pyloroplasty, invasive monitoring may not be necessary, but when associated with a more complex operation such as esophagectomy, invasive monitoring is required.

POSITION

When pyloroplasty is combined with Nissen fundoplication or esophagectomy, the patient is positioned with their arms tucked and their legs abducted. Because the pylorus is not a midline structure, an isolated pyloroplasty may be best approached with the surgeon standing on the left side of the patient working in a triangulated fashion toward the pylorus, somewhat similar to the approach for laparoscopic cholecystectomy. Regardless of the patient position, pneumatic compression boots are applied and a first-generation cephalosporin is given intravenously (Figure 1).

INCISION AND EXPOSURE

When part of a Nissen fundoplication, the pyloroplasty is usually performed by introducing an additional 5-mm trocar just to the patient’s right of the umbilicus which can be used for the surgeon’s left hand (Figure 2A). When performed as a stand-alone procedure, the laparoscopic pyloroplasty is performed from the patient’s left side with the left hand (5-mm trocar) through a umbilical approach, the camera is positioned to the left ...

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