Vagotomy

Vagotomy is an essential component of surgical management of peptic (duodenal and gastric) ulcer disease (PUD). Vagotomy was once commonly performed to treat and prevent PUD; however, with the availability of excellent acid secretion control with H2-receptor antagonists (H2RAs; eg, cimetidine, ranitidine, and famotidine), proton pump inhibitors (PPIs; eg, pantoprazole, rabeprazole, omeprazole, esomeprazole, and lansoprazole), and anti–Helicobacter pylori medications, the need for surgical management of this condition has greatly decreased.

The basic types of vagotomy are as follows:

• Truncal vagotomy (TV) ^[1]
• Selective vagotomy (SV)
• Highly selective vagotomy (HSV)

All types of vagotomy can be performed at open surgery (laparotomy) or by using a minimally invasive approach (laparoscopic or robotic).

For the management of PUD, vagotomy is sometimes combined with antrectomy (removal of the distal half of the stomach) to reduce the rate of recurrence. Reconstruction after antrectomy is performed with gastroduodenostomy (Billroth I) or gastrojejunostomy (Billroth II).

Vagotomy is indicated as management of PUD in the following cases:

• Elective - Failure of medical treatment (with the availability of effective acid suppression with H2RAs and PPIs; however, this indication has virtually become nonexistent)
• Semielective - Pyloric stenosis (obstruction) due to PUD (vagotomy performed as an adjunct to a pyloric drainage or bypass procedure) 
• Emergency - Upper gastrointestinal (GI) bleeding due to PUD ^[2] or stress gastric ulcers (erosive gastric mucosal disease) or perforated PUD that is causing peritonitis
• Incidental - An inadvertent vagotomy performed during esophagectomy or esophagogastric devascularization procedures for bleeding varices caused by portal hypertension; the pylorus is usually disrupted (dilatation, pyloromyotomy, or pyloroplasty), but some surgeons leave it intact

Some have suggested that thoracoscopic TV may be useful for management of recalcitrant marginal ulcer after Roux-en-Y gastric bypass. ^[3]  

Virtually no contraindication for vagotomy exists; however, indications for its use have become less common.

Anatomy

The thoracic esophagus enters the abdomen via the esophageal hiatus in the left hemidiaphragm at the T10 level and has a short (2-3 cm) intra-abdominal length. The esophagogastric junction (EGJ, or cardia) lies in the abdomen below the diaphragm to the left of the midline. The cardiac notch (incisura cardiaca gastris, or incisura cardialis) is the acute angle (of His) between the left border of the intra-abdominal esophagus and the fundus of the stomach (the part of the stomach above a horizontal line drawn from the cardia) that lies under the left dome of the diaphragm and is closely related to the spleen.

The body (corpus) of the stomach leads to the prepyloric antrum (at the incisura angularis, which lies on the lesser curvature about 6-7 cm proximal to the pylorus) and joins the duodenum at the pylorus to the right of the midline.

The stomach (along with the first part of the duodenum) is attached to the liver by the gastrohepatic ligament (lesser omentum), to the left dome of the diaphragm by the gastrophrenic ligament, and to the spleen by the gastrolienal ligament.

For more information about the relevant anatomy, see Stomach Anatomy and Duodenal Anatomy.

The esophageal plexus of the vagus (parasympathetic) nerve lies in the posterior mediastinum below the hila of the lungs. It changes into two vagal trunks that enter the abdomen along with the esophagus through the esophageal hiatus in the left dome of the diaphragm. The right (posterior) vagus lies behind and to the right of the intra-abdominal esophagus, separate from the esophagus, between the esophagus and the right crus of the diaphragm, whereas the left vagus lies in front of the intra-abdominal esophagus and is closely attached to the anterior surface of the esophagus.

The right (posterior) vagus gives rise to a posterior gastric branch called the criminal nerve of Grassi—so called because it is often missed during vagotomy and is then responsible for the recurrence of PUD—which traverses to the left and supplies the cardia and the fundus. The right (posterior) vagus gives rise to one or more celiac branches, which supply the pancreas and the small and the large bowel, and the left (anterior) vagus gives rise to one or more hepatic branches, which supply the liver and gallbladder. The celiac and hepatic branches run between the two peritoneal leaves of the lesser (gastrohepatic) omentum.

For more information about the relevant anatomy, see Esophagus Anatomy and Vagus Nerve Anatomy.

After giving rise to the celiac and the hepatic branches, respectively, the right  (posterior) and the left (anterior) vagal trunks continue along the lesser curvature of the stomach (in close company with the vascular arcade formed by the left and the right gastric vessels) as the posterior and anterior gastric nerves of Latarjet, which supply the corpus (body), antrum, and pylorus of the stomach.

In some anatomic texts, the terminal parts of the right (posterior) and left (anterior) vagi, after the gastric branches have been given off, are described as the anterior and posterior gastric nerves of Latarjet. The branches of the vagi to the antropylorus are also described as a crow’s foot that extends proximally to a distance of about 7 cm from the pylorus.

The celiac trunk (axis) comes off as its first branch from the anterior surface of the abdominal aorta. It is about 1 cm long and trifurcates into the left gastric artery (LGA), the common hepatic artery (CHA), and the splenic artery. The LGA runs toward the lesser curvature of the stomach and divides into an ascending branch (supplying the intra-abdominal esophagus) and a descending branch (supplying the stomach), both of which run along the lesser curvature.

The CHA runs toward the right on the superior border of the proximal body of the pancreas and continues as the proper hepatic artery (PHA) after giving off the gastrodudoenal artery (GDA). The right gastric artery (RGA), a branch from the CHA or the PHA, runs along the lesser curvature from right to left and joins the descending branch of the LGA to form an arcade along the lesser curvature between the two leaves of the peritoneum of the lesser omentum. The pylorus is marked by a prepyloric vein of Mayo.

Procedural planning

TV includes division of the main trunk of the vagus (including its celiac/hepatic branch) and denervation of the pylorus; therefore, it is necessary to perform a pyloric drainage procedure, such as pyloric dilatation or disruption (pyloromyotomy or pyloroplasty), or a pyloric bypass procedure, such as gastrojejunostomy. This procedure also denervates the liver, biliary tree, pancreas, and small and large bowel.

TV as a surgical procedure for duodenal ulcer was performed by Dragstedt in the 1940s. Initially, the operation was performed through a transthoracic approach and a gastric drainage procedure was not added; later, it was performed through laparotomy and drainage procedures were added.

SV includes division of the anterior and posterior gastric nerves of Latarjet only (after the celiac/hepatic branches have been given off). It also denervates the pylorus, and therefore, a pyloric drainage or bypass procedure is needed. It does not denervate the liver, biliary tree, pancreas, or small and large bowel. This procedure is rarely performed today.

HSV includes denervation of only the fundus and the body (the parietal cell–containing areas) of the stomach (hence also called parietal cell vagotomy [PCV]). It preserves the nerve supply of the antrum and the pylorus; consequently, a pyloric drainage or bypass procedure is not needed. HSV does not denervate the liver, biliary tree, pancreas, or small and large bowel. This procedure is also called proximal gastric vagotomy (PGV).

Studies in Asian populations have suggested that in patients with complicated PUD (perforation or bleeding), vagotomy reduces the risk of subsequent ischemic heart disease and stroke as compared with simple suture closure or nonoperative hemostasis. ^{[4, 5]}

Some preliminary evidence from Scandinavian studies has suggested that TV, though not SV, may have some protective effect against Parkinson disease also. ^{[6, 7]}