1. Surgical Approach and Placement of Ports

2. Robot Docking

3. Exposure

4. Longitudinal Pyloric Myotomy

5. Hemostasis

6. Transverse Pyloric Closure

7. Leak Test

8. Closure and Robot Undocking

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.

<h4>CHAPTER 1</h4>

<p>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.</p>

<h4>CHAPTER 2</h4>

<p>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.</p>

<h4>CHAPTER 3</h4>

<p>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.</p>

<h4>CHAPTER 4</h4>

<p>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.</p>

<h4>CHAPTER 5</h4>

<p>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.</p>

<h4>CHAPTER 6</h4>

<p>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.</p>

<h4>CHAPTER 7</h4>

<p>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.</p>

<h4>CHAPTER 8</h4>

<p>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.</p>


Watch this full-length, narrated surgical video of a robotic Heineke-Mikulicz pyloroplasty for pyloric stenosis performed by Dr. Nicole Cherng at UMass Memorial Medical Center.

UMass Memorial Medical Center