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Pyloric stenosis resulting in gastric outlet obstruction can present with nausea, vomiting, and early satiety. Imaging including fluoroscopic upper gastrointestinal series and computed tomography can diagnose gastric outlet obstruction. Upper endoscopy is included in the work-up to visualize the extent of stenosis and to obtain a tissue biopsy. After a malignancy is ruled out, treatment involves management of underlying causes. This may include acid suppression, treatment of H. pylori, and dietary modification. Patients who fail conservative management may benefit from endoscopic therapies including pneumatic dilation and botulinum toxin injection. However, these therapies may not offer lasting symptomatic relief. Pyloroplasty can be performed with the goal of widening the pylorus to improve gastric emptying. Pyloroplasty can be accomplished through open, laparoscopic, and robotic techniques. Here we describe a robotic-assisted Heineke-Mikulicz pyloroplasty in an adult patient with benign pyloric stenosis.
Robotic surgery; gastric outlet obstruction; pyloroplasty; minimally-invasive surgery.
Pyloric stenosis is a common cause of gastric outlet obstruction (GOO) in adults and is most commonly caused by malignancy, closely followed by peptic ulcer disease. Hypertrophic pyloric stenosis presenting in adulthood is rare.1, 2 Ruling out an underlying malignancy is important to offering treatment. Patients commonly present with nausea, vomiting, and early satiety.3
Here we present a 66-year-old woman with a past medical history significant for Barrett’s esophagus, chronic obstructive pulmonary disease, hypothyroidism, and prediabetes. She presented for evaluation of an approximately 1-year history of gastric reflux, early satiety, and projectile vomiting. Due to her symptoms and a family history of Barrett’s esophagus and esophageal cancer, she underwent an upper endoscopy around the time of symptom onset, which revealed Barrett's esophagus, a hiatal hernia, and retained liquids and solids in the stomach. The pylorus could not be transversed. She was prescribed omeprazole 40 mg daily. She underwent three pyloric dilations with pneumatic dilation up to 12 mm and a botulinum toxin injection during one of the endoscopies. These resulted in minimal and short-lived symptom relief. Multiple biopsies were taken and were all negative for malignancy. Due to continued symptoms she presented for robotic-assisted pyloroplasty.
The patient had no prior abdominal surgeries. Her medications include hydrochlorothiazide, omeprazole, levothyroxine, rosuvastatin, albuterol, and fluticasone proprion-salmeterol. She is a former smoker. She has no drug allergies.
Physical exam revealed a well-nourished and healthy-appearing woman. She was in no apparent distress with vital signs within normal limits. Her BMI was 28.5kg/m2. Her abdomen was soft, non-distended, non-tender, with no palpable masses.
Fluoroscopic upper gastrointestinal (UGI) series is diagnostic for GOO but does not differentiate between underlying causes.2, 4 Computed tomography (CT) scan of the abdomen with oral and intravenous contrast offers the advantages of better defining the anatomy of the UGI and can potentially identify an underlying malignancy.
This patient underwent a CT scan of the abdomen and pelvis with oral and IV contrast. This revealed a possible 1.2-cm exophytic lesion at the pylorus. This finding raised the concern for a possible gastrointestinal stromal tumor or thickening secondary to peptic ulcer disease. A nuclear gastric emptying study showed severely delayed gastric emptying. A fluoroscopic UGI series showed no obstruction but was significant for delayed passage of contrast through the pylorus.
The pylorus is composed of a thick inner layer of muscle that is contiguous with the inner layer of gastric muscle. This inner muscle layer is separate from the inner layer of muscle in the duodenum. There is also a thinner outer layer of muscle in the pylorus. These longitudinal muscle fibers are continuous from the stomach and reach the duodenum.1, 2
Adult pyloric stenosis falls into two main categories. Primary pyloric stenosis is a rare entity and thought to be persistent hypertrophic tissue that has been present since infancy.2, 5 Secondary pyloric stenosis is by far the most prevalent variety. Secondary pyloric stenosis is most commonly caused by malignancy and peptic ulcer disease.2 In a series of 100 patients with pyloric stenosis 42% were due to malignancy and 37% due to peptic ulcer disease.1
A stenotic or occluded pylorus prevents adequate gastric emptying. Clinical manifestations typically include nausea and vomiting, which may be projectile in nature. Early satiety may also be present. Symptoms typically occur over weeks to months. They may occur more acutely due to an ulcer within the pylorus.3 Patients may have varying levels of tolerance of oral intake. It is important to account for a patient’s nutritional and metabolic status before proceeding with any intervention as they may require resuscitation and nutritional optimization.
Patients should be treated in a stepwise fashion based on a patient’s degree of symptoms and tolerance for invasive procedures. Dietary modifications with small meals and softer textures may alleviate symptoms in a portion of patients. Next, upper endoscopy may be both diagnostic and therapeutic. Balloon dilation may offer relief of symptoms but does not typically offer long-term improvement.6, 7 Finally, there are several surgical options for treatment including pyloroplasty, pyloromyotomy, gastrojejunostomy, and distal gastrectomy.8
This patient had persistent symptoms despite repeated attempts at medical and endoscopic management. Given these failures, pyloroplasty was indicated to open the pylorus and allow for adequate gastric emptying. The surgeon chose a minimally-invasive approach.
Here we discuss a case of a 66-year-old woman with pyloric stenosis that was refractory to medical and endoscopic management. Despite multiple endoscopic balloon dilations and injection of botulinum toxin, she remained symptomatic. Due to continued symptoms she underwent an uncomplicated robotic-assisted Heineke-Mikulicz pyloroplasty. On postoperative day two she underwent a Gastrografin swallow study, which showed no evidence of leak and passage of contrast into the duodenum. It is our practice to routinely obtain a contrast swallow study on postoperative day two or three, prior to diet initiation. She was discharged home on a full liquid diet for three days, followed by a soft diet. She tolerated this advancement well. At 3- and 6-week follow up she was recovering well with tolerance of diet advancement with the integration of cooked vegetables.
Endoscopic evaluation is an essential step for the diagnosis and treatment of GOO. The pylorus should be visualized and biopsied to determine the presence or absence of malignancy causing obstruction. As in our patient, the duodenum may be inaccessible during endoscopy depending on the extent of stenosis. Endoscopic therapies may offer some short-term symptom relief but they do not produce lasting results for many patients.6 Patients that fail endoscopic therapy should be referred for surgical evaluation.
Pyloroplasty is typically carried out using the Heineke-Mikulicz or Finney techniques.3 Pyloroplasty carries less morbidity than larger operations such as gastrectomy. Considering the benign nature of this disease, less invasive and morbid treatments should be carefully considered before committing a patient to a larger surgery. Pyloroplasty can be performed using open, laparoscopic, and robotic techniques. The decision of which technique to employ largely depends on surgeon preference and comfort. The decision to perform a Heineke-Mikulicz in this case was due to surgeon preference.
The robotic-assisted approach to pyloroplasty is performed in a similar fashion to laparoscopic techniques. Patient positioning and port placements require careful consideration and planning to perform adequate exposure and reach of instruments. Ports were placed in the supraumbilical, right lateral, right mid, and left mid areas of the abdomen. The patient was placed with the right side up and in slight reverse Trendelenburg positioning. A 30-degree robotic camera was placed in the right mid-abdomen. A robotic Cadiere grasper was used to better expose the pylorus. This retraction allows for two working hands and the robotic camera, all under the control of the operating surgeon. A longitudinal incision is placed through the pylorus, extending from the distal antrum to the proximal duodenum, which was closed transversely in two layers using 2-0 V-Loc (Medtronic Minneapolis, MN) sutures. A modified Graham patch with omentum was placed to re-enforce the repair.
The first laparoscopic pyloromyotomy for pyloric stenosis was performed in 1990.9 Danikas et al described a laparoscopic pyloroplasty in an adult patient.8 Shada et al demonstrated the safety and effectiveness of a laparoscopic pyloroplasty in their series of 177 patients with gastroparesis. There were 0 conversions to laparotomy, a 1.1% leak rate, and 2.2% of patients had to return to the operating room.10
When compared to laparoscopic pyloroplasty, robotic pyloroplasty was found to have shorter operative time (90.0 min vs 122.4 min p=0.0061) and length of stay (2.7 days vs 4.0 days p=0.011). Cost was higher for robotics by $511.17 (p=0.025), but there was no difference in total cost of hospitalization. The authors attribute the decreased operative time during robotic pyloroplasty to the improved dexterity offered by the robotic platform. The fact that there was no significant difference in overall cost despite the increased cost of using the robotic platform can be attributed to the significant decrease in length of stay in the robotic group.11 We agree that the improved dexterity in addition to the superior field of view makes the robotic approach ideal.
Benign pyloric stenosis can be a cause of GOO in adults. Robotic-assisted Heineke-Mikulicz pyloroplasty is a safe, effective, and long-lasting treatment for benign pyloric stenosis in adults.
This surgery was performed using the DaVinci Xi robotic platform (Intuitive Surgical, Sunnyvale, CA).
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Quigley RL, Pruitt SK, Pappas TN, Akwari O. Primary hypertrophic pyloric stenosis in the adult. Arch Surg. 1990;125(9):1219-1221. doi:10.1001/archsurg.1990.01410210145025.
- Hellan M, Lee T, Lerner T. Diagnosis and therapy of primary hypertrophic pyloric stenosis in adults: case report and review of literature. J Gastrointest Surg. 2006;10(2):265-269. doi:10.1016/j.gassur.2005.06.003.
- Søreide K, Sarr MG, Søreide JA. Pyloroplasty for benign gastric outlet obstruction--indications and techniques. Scand J Surg. 2006;95(1):11-16. doi:10.1177/145749690609500103.
- Khullar SK, DiSario JA. Gastric outlet obstruction. Gastrointest Endosc Clin N Am. 1996;6(3):585-603.
- Knight CD. Hypertrophic pyloric stenosis in the adult. Ann Surg. 1961;153(6):899-910. doi:10.1097/00000658-196106000-00010.
- Lau JY, Chung SC, Sung JJ, et al. Through-the-scope balloon dilation for pyloric stenosis: long-term results. Gastrointest Endosc. 1996;43(2 Pt 1):98-101. doi:10.1016/s0016-5107(06)80107-0.
- Kochhar R, Kochhar S. Endoscopic balloon dilation for benign gastric outlet obstruction in adults. World J Gastrointest Endosc. 2010;2(1):29-35. doi:10.4253/wjge.v2.i1.29.
- Danikas D, Geis WP, Ginalis EM, Gorcey SA, Stratoulias C. Laparoscopic pyloroplasty in idiopathic hypertrophic pyloric stenosis in an adult. JSLS. 2000;4(2):173-175.
- Alain JL, Grousseau D, Terrier G. Extramucosal pyloromyotomy by laparoscopy. Surg Endosc. 1991;5(4):174-175. doi:10.1007/BF02653256.
- Shada AL, Dunst CM, Pescarus R, et al. Laparoscopic pyloroplasty is a safe and effective first-line surgical therapy for refractory gastroparesis. Surg Endosc. 2016;30(4):1326-1332. doi:10.1007/s00464-015-4385-5.
- Bajpai S, Khan A, Rutledge KM, Stahl RD. Impact of robotic versus laparoscopic pyloroplasty on short- and long-term outcomes in patients with gastroparesis. J Gastrointest Surg. 2021;25(10):2679-2680. doi:10.1007/s11605-021-04986-3.
Cite this article
Durgin J, Mackey E, Cherng N. Robotic Heineke-Mikulicz pyloroplasty for pyloric stenosis. J Med Insight. 2023;2023(422). doi:10.24296/jomi/422.
Table of Contents
All right, let's go 11 blade. Veress. Veress. Gas on. 50 and 50. Place. Great. All right, that looks good. Let me see. I'm not having a great flow, there you go. It's going, there you go. Insufflating. All right, so this is a 66-year-old woman who has essentially, was having a fair amount of heartburn and then got an upper endoscopy, which showed a fair amount of undigested food within the stomach and a very tightened pylorus. GI had done multiple dilations. They can only get up to about 12 mm. She then got referred to me; we did a gastric emptying, which showed severe delayed gastric emptying. I did dilate her to a 12, 15-mm TTS balloon a few months ago and did a Botox injection at the pylorus. She had some response to that, but really not great, and just given how tight it was, we felt that a pyloroplasty would be the best option for her. In addition to our workup, we also did a CT of the abdomen/pelvis, which didn't show any evidence of any gastric extrinsic mass. So for port placement, we're gonna do all four ports. All 8-mm robotic ports similar to what you would do, almost like, for a gallbladder. And so, we're gonna go - our first one, just right about here. She hasn't had any prior abdominal surgeries, which works in our favor. All righty. All right, switch the gas, keep the Veress on for this one. Alrl ighty, Valerie, we're recording? Excellent. Let's take a look. All right, so that's good. There you go. All righty, okay. So, knife to me. All right, cutting twice. Good, next eight. And then Tim, when you're ready, we'll take some positioning. I'll take 13 degrees reverse Trendelenburg, and actually a 3-degree roll away from me, towards Emily. I'll go bed all the way down. All right, just let me just see the, come through here. Let's just take a quick look. I would just go all the way down. And then a 3-degree roll towards Mackey. All right, so we don't see... So big stomach - nice, big and dilated. No evidence of anything else concerning. Okay, we're ready for the robot. Upper abdomen, patient left, please. All right, three - three degrees, airplane up. Towards Emily - so away from me. Yeah. All right, there you go. Perfect.
Oh, you can push it back now. That's fine, you can push it back up, actually. All right, come on in. Stop. Let me just see, to the head of the bed. Oh no, you're good Tristan. Keep going. Good, a little bit more. Stop, can you actually pull back towards you? I'll stay true to who I am and not target. The operating table is not paired with DaVinci. Camera - you give a good wipe, Kel? Burp your ports. Can you put the smoke vac back on? All right, so for arms I'm gonna take a fenny bi. Cadiere in four. All right, that's arm one. Come on in. You're high. Okay, great. All righty, we can go - room lights off.
All righty, so we have a 30-degree camera. Our arms; in arm one we're using a fenestrated bipolar, in arm three, a monopolar scissors, and arm four, a Cadiere. Patient's position, reverse Trendelenburg, tilted a bit towards the patient left. So here, you can feel the pylorus is about somewhere over here. So I'm just gonna kinda mobilize it this way. Okay. So it starts, based off palpation, probably right around here. So I'm just gonna kind of roll just a little bit. Just gonna take off this layer of fat that sits over it, first. Okay. Just kind of release it. It's just a little more mobilized. Okay. So you can imagine that the pylorus... Is somewhere around here.
All right, so we're gonna do a Heineke-Mikulicz pyloroplasty. There we go. So I'm just gonna score where approximately where I'm gonna go first. Or I imagine my... Oh, can I have the smoke vac on, please? Yeah, that's great. Thank you. Just confirming my anatomy. So some people use the hook. You can use the hook or the scissors for this part. I think as long as you have energy that's all that really matters. So I'm not gonna go quite yet to the duodenum side. I'm just gonna focus on getting in more on the stomach side. So I'm gonna slide my instruments in. A little more release. Now, if you're doing a pyloromyotomy for pyloric stenosis in children, you just wanna get the muscle and then leave the mucosal layer intact. But here we can go full thickness. So that's most of the muscle, very thickened. I have my... It should be in. There we go. It's definitely in. You can see how thickened it is because that's duodenal side, and already, you can already see it's narrowing because it's so thickened that this is actually, it's lumen. Is where my grasper is entering, so you can already tell that it's very thickened because even though I thought I was entering what I thought was the middle; this is already its entire thickened wall. She's had multiple dilations in the past, so this is gonna be fairly scarred down. We know the lumen is only about 1 cm. And so that's on the gastric side. I'm just gonna take a little bit more so that we're absolutely sure. That we have a complete myotomy. 2-0 V-loc. This is like, really thick. Okay, so there's my grasper going into the stomach side. So this is the pylorus. This is very tight, it's very thickened. So we just wanna make sure that we get into... Above it, well, okay. You just need to know that you have it complete. So here, we're clearly in duodenum because you can see bile coming up and it's very thin walled. So we probably, we probably got closer on the duodenum side than I initially expected, but this you can just tell that's the thickened pylorus, so you can kind of see there. And then her stomach, it has poor emptying so it's probably a little thicker than maybe the average stomach, but you can see how it thins out over here. Its compliance is much thinner. So we'll just take it a little bit more just to be absolutely confident. So now you know you're on stomach side. So that's your... So this is your pylorus, you can see it's incredibly narrowed because that's the only lumen that she had, was there.
All right, so before we start to close it, we'll just get hemostatic and just clean up a little bit. Can you take down arm four, and then I'm just gonna have you come in with a sucker and just clean up a little bit for us. The OG tube, if you can take it off suction, now that I have a hole in the stomach, so that we don't lose too much pneumo. Thank you. Just kind of clean up. Yeah, that's good. That's good, all right. That should be good. And just suction that little bit of blood back there. Okay, great. All right, and then if we could... Do you have a 2-0 V-loc? All right, if you can come in with that 2-0 V-loc... You can come through arm four. You can take out the monopolar scissors, and I'll take the needle driver, please. Okay, coming out with arm three. Great. And I'll take the Cadiere back in four after the suture. Needle coming in arm four. Uh-huh. I see you, open. Got it, close.
All right, so for closing the pyloroplasty. So you're gonna close in a linear fashion. So, Heineke-Mikulicz. Coming in arm four. Thank you. And then, you can do interrupteds, you can do - I'm choosing to do a barbed, an absorbable, barbed suture. But ultimately you wanna be able to close in two layers. Come on in. Coming in on three. Thank you. You ultimately wanna close in two layers. And then that's essentially... So if you imagine, we cut here to here; you kind of split the difference. You can imagine here's gonna be your new apex. So you wanna, and when you close this way in order to make it as wide as possible. So it's very thickened here, so I'm gonna try to get full-thickness bites. Oh very, very thick. Yep. Okay. Just gonna lift the... So again, I'm trying to make sure I'm at the mucosal level. Just gonna hand this to my arm four to help me elevate to set up for sewing. So here, you really wanna make sure you got mucosa: all layers, full thickness. And then our second layer will just be seromuscular bites just to Lembert it in. And as this comes together, it should help with its hemostasis as well. I think I'll just keep that up there. So we talked - I did talk to this patient about you know, etiologies of this is likely, peptic ulcer disease. We did talk, the discussion of potentially doing a gastrojejunostomy as well, given that she has, after many months to years of having this fairly, significantly delayed or this pyloric stenosis, her stomach has lost a lot of its motility. However, she wanted to go in sort of a less-invasive to more-invasive. And so she wanted to see how well she responded to this before subjecting her to an anastomotic procedure, which I thought was more than reasonable. I think you just really want to take your time to make sure that you're really getting full-thickness bites here. I'm not gonna cinch down until the very end. Emily, why don't you take out arm four and come in with a suction irrigator. Just clean up, so I have an optimal view. Just suction right in here and over here. I'm gonna undock arm four. That's fine. Go ahead. Yeah, just suction all of that junk. Suction up there, and then just suction right in there for me. A little bit right there. Okay, good. All right, I'm gonna cinch it down. I need you to just give it a quick clean. Yep. All right. Just gonna go all the way down to the apex. And then I'll start my second layer, which will just be seromuscular bites just to Lembert this in. Oh. It's still bleeding. So it looks like I... Huh. Suction on here. I'll wait for you. It's a little deeper. Okay, so knowing that I'm just gonna kind of take a deeper bite. Suction. That's better. I'm gonna try to stay a little more superficial. You don't wanna narrow it, obvious... Can I take arm four back, now? Yep. Come on in. Oh, I'll back off. There you are. That's good. So we will do a leak test in a few minutes, Tim. I just wanna make sure I get all the way back. Now I've also had some where, it just for whatever reason, if the tissues I'm not as confident in; sometimes I will mobilize, you know, a piece of omentum or fat to act as a, almost a Graham patch over the repair. Which we could easily do in somebody like her. So it'd just be like, something like that, and then I usually just tack it to the fat with the barbed and then maybe put a silk here and a silk there. But before we do that, we'll go onto our leak test first. Okay.
So why don't we take out arm three. Okay. And then Tim, for our leak test, the usual, the oxygen; I'll let you know. Three coming out. Yep. All right, why don't you suction up the blood first, just to make sure that's not bleeding. Coming in now. Yep. Give us a second, Tim. Thank you. So I'm gonna occlude distally. Just clean up first, great. All right, great. Okay, good. All right, let's go one liter per minute. So there, it's going down the OG tube, which you can see is filling. So I'm just gonna... Let me just get a little more distal. So you see? I... Irrigate just a little bit. There we go. All right, good. Stop. All right. That's good. Yep, you can put it back to suction. So you can tell air that's definitely filling the duodenum. No obvious leak.
All right, so we'll put that OG tube back to suction. Okay great, can you just put that OG back to suction, please? Yeah, will do. Thank you. Uh - suction here. What's going on? Let's just look at this. Something is - just gently... I think that's better. Do you want arm three back in? Yeah, before you do that though, why don't we do - why don't you get me one, 2-0 silk. So I'm just gonna patch it in some fat. 2-0 silk, cut to seven. That's good. I'll take that stitch first. 2-0, please. And we'll just put one tacking stitch here, and then we'll be done. Patient will stay overnight and then she'll go home ultimately on a modified diet. So, sort of like, a full liquids, and then eventually to puree and then soft. And then she'll, we'll see how well it tolerates. Immediate... Oh, go ahead. Immediately postoperatively, there is some swelling at this area, so it's not uncommon. I'll take the needle driver back. So, it's not uncommon. So that's why we send them out on a modified diet. Coming in arm three. Great. Are you coming in? Oh, there you are. Okay, that's good, I'll take it there. Yeah, set that needle aside. Let's take one last look. Make sure we're hemostatic. Nothing seems to be welling up. All right, why don't you take out arms three or four, whichever one's easier for you to take out these needles. One needle. All right, all instruments out. You can undock. Tristan, just go south first, just in case. All right, all needles are out. You can level the patient. Okay. Q-tip. Oh, let's just take one last look. Yes, please. I think it'll be okay. Okay, all right. Very good. Ooh, all right. All right, gas off. Can I have a a sponge? So, she'll stay in the hospital for tonight, or actually two nights. I'll do a swallow on post-op day 2 just to see - there's usually postoperative swelling to be expected. And then she'll go home on a liquid diet for a few days and slowly, ultimately be advanced to a soft diet. All right, I'll take a stitch. Needle up on your Mayo. Just dab for me. All right, wet and a dry. All right, one needle. I'll take a glue. I'll just make this look pretty. Oh, it's contaminated, superficial only. Correct. Okay.