Small Intestine: Stricturoplasty

Stricturoplasty

Choice

  • Short (< 7-10 cm): Heineke-Mikulicz Stricturoplasty
  • Intermediate (> 7-10 cm): Finney Stricturoplasty
  • Long (> 15-20 cm): Michelassi Stricturoplasty

Principals

  • Always Inspect Mucosa to Rule Out Underlying Malignancy & Bx Any Suspicious Lesions
  • Ensure Hemostasis

Heineke-Mikulicz Stricturoplasty

  • Most Common Approach
  • For Small (< 7-10 cm) Strictures
  • Procedure:
    • Isolate the Diseased Segment
    • Make a Longitudinal Incision Along the Antimesenteric Border
      • Extend 2 cm Proximal & Distal to the Structured Area
    • Close the Incision Transversely
      • Use Traction Sutures at the Midpoints to Pull and Assist in Closure
      • Close in 1-2 Layers

Finney Stricturoplasty

  • For Intermediate (> 7-10 cm) Strictures
  • Procedure:
    • Isolate the Diseased Segment
    • Diseased Segment is Folded onto Itself at the Midpoint
    • Make an Extended “U-Shaped” Incision Along the Antimesenteric Border
      • Extend 2 cm Proximal & Distal to the Structured Area
    • Closed Side-to-Side
      • Start at the Middle
      • Suture Inferior Leaf of the Proximal Half to the Inferior Leaf of the Distal half
      • Continue to Suture the Superior Leaves
      • Finish with a Layer of Lembert Sutures to Invert

Michelassi Stricturoplasty

  • For Large (> 15-20 cm) Strictures
  • Procedure:
    • Isolate the Diseased Segment
    • Transect Diseased Segment at the Midpoint
    • Transfer the Proximal Limb Next to the Distal Limb
      • Lay in an Isoperistaltic Side-to-Side Manner
    • Place a Posterior-Row of Nonabsorbable Suture to Approximate
    • Make Longitudinal Incisions Over the Approximated Sides to Spatulate
    • Close Internal Layers with a Running Absorbable Suture
    • Oversew the Anterior Layer with Nonabsorbable Suture

Other Stricturoplasty Options

  • Jaboulay Stricturoplasty
    • Side-to-Side Anastomosis Bypassing the Strictured Segment
    • Use: If Stricture is Too Tight or Unable to Suture
  • Moskel-Walske-Neumayer Stricturoplasty
    • “Y” Incision Closed Transversely
      • V Portion in Dilated Bowel
    • Use: If Stricture Short with Significant Size Difference Between Proximal & Distal Segments

Complications

  • Most Common: Bleeding
  • Anastomotic Leak
  • Dehiscence
  • SBO

Heineke-Mikulicz 1

Finney 1

Michelassi 1

Jaboulay 1

Moskel-Walske-Neumayer 1

References

  1. Oliveira EC, Bafutto M, Bafutto AAF, Neto SG, Neto JJB. Current Elective Surgical Treatment of Inflammatory Bowel Disease. Current Topics in Colorectal Surgery, IntechOpen, 2021. (License: CC BY-3.0)