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, now that excellent acid secretion control can be achieved 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.[1]

The basic types of vagotomy are as follows:

• Truncal vagotomy (TV) ^[2]
• 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 become virtually nonexistent)
• Semielective - Pyloric stenosis (obstruction) due to PUD (vagotomy is performed as an adjunct to a pyloric drainage or bypass procedure) 
• Emergency - Upper gastrointestinal (GI) bleeding due to PUD ^[3] or stress gastric ulcers (erosive gastric mucosal disease) or perforated PUD that is causing generalized peritonitis
• Incidental - An inadvertent vagotomy is performed during esophagectomy or esophagogastric devascularization for bleeding varices caused by portal hypertension; after this, the pylorus is usually disrupted (dilatation, pyloromyotomy, or pyloroplasty), but some surgeons leave it (the pylorus) intact

Some have suggested that thoracoscopic TV may be useful for management of recalcitrant marginal ulcer after Roux-en-Y gastric bypass.[4]  

A vagal-sparing esophagectomy may be considered for patients with end-stage benign disease and Barrett high-grade dysplasia or intramucosal adenocarcinoma.[5]

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 (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 also 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 the 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 left (anterior) vagal trunks continue along the lesser curvature of the stomach (in close company with the vascular arcade formed by the left and 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 either 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 trunks of both the vagus nerves (including their celiac and hepatic branches) 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. TV also denervates the liver, the biliary tree, the pancreas, the small bowel, and the colon.

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). SV also denervates the pylorus, and therefore, a pyloric drainage or bypass procedure is needed (as in TV). It does not denervate the liver, the biliary tree, the pancreas, or the small or 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 (and hence is 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, the biliary tree, the pancreas, or the small or large bowel. This procedure is also called proximal gastric vagotomy (PGV).

Vagotomy may have some long-term incidental benefits. 

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.[6, 7]

Some preliminary evidence from Scandinavian studies has suggested that TV, though not SV, may have some protective effect against Parkinson disease also.[8, 9]

A blood transfusion may be needed for patients with a bleeding peptic ulcer.

Resuscitation, fluid and electrolyte imbalance correction, and antibiotics should be administered, as needed, in patients with a perforated peptic ulcer.

Patients with pyloric stenosis due to peptic ulcer disease (PUD) causing gastric outlet obstruction (GOO) have dehydration, alkalosis, and hypokalemia, which should be corrected with the administration of normal saline solution and potassium chloride. Gastric aspiration and lavage are required to decompress the dilated stomach.

A nasogastric tube in situ allows easier intraoperative identification (palpation) of the esophagus.

In patients who have undergone previous vagotomy (or any gastric surgery) and in whom another vagotomy is required for recurrence of an ulcer, a thoracic approach (thoracotomy or thoracoscopy) is better than an abdominal approach because of the presence of adhesions in the abdomen.

A table-mounted sternal elevator and a self-retaining abdominal wall retractor may obviate the need for an assistant.

Anesthesia

General anesthesia is used for this procedure.

Positioning

The patient is placed in the supine position; a slight reverse Trendelenburg (head up) orientation may be used in order to displace the intestines caudad. For the thoracic approach, the patient is placed in a right lateral (left side up) position.

The steps in a truncal vagotomy (TV) are as follows.

The spleen is protected with a pack.

The left lateral section (also called segment) of the liver is mobilized by dividing the left triangular ligament (with care taken not to injure the inferior phrenic vein and the left hepatic vein), then retracted with a deep flat-bladed retractor.

The upper part of the stomach is retracted downward, and the visceral peritoneum over the anterior surface of the lower (intra-abdominal) esophagus is opened transversely across the length of the esophagus.

The esophagus is mobilized all around by means of blunt dissection and is encircled with a soft sling (eg, umbilical tape) or a drain (eg, Penrose). It should be noted that some surgeons are of the opinion that circumferential mobilization of the esophagus weakens the esophageal hiatus and therefore do not mobilize it all around.

In addressing the vagus nerves, it should be kept in mind that whereas the right (posterior) vagus is usually a single trunk, the left (anterior) vagus can be multiple in as many as one third of cases.

The anterior (left) vagus is better seen on the anterior surface of the intra-abdominal esophagus as it indents the anterior wall of the esophagus as a vertical sling. This indentation is made more prominent by retracting the upper part of the stomach downward to render the esophagus taut.

The anterior vagus is mobilized from the esophageal wall with a right-angle clamp, and a 2- to 3-cm segment is excised between ligatures or clips. It is important to look carefully for multiple smaller additional anterior vagus nerves on the anterior surface of the esophagus that can be lifted by using a nerve hook; these should also be divided to complete the vagotomy.

The posterior (right) vagus is better felt as a taut bowstring or cord behind and to the right of the intra-abdominal esophagus. Unlike the anterior vagus, which is closely attached to the anterior surface of the esophagus, the posterior vagus usually lies away from the esophageal wall in loose areolar tissue on the right crus of the diaphragm.

Exposure of the posterior vagus is facilitated by retracting the slinged esophagus to the left. As noted, the posterior vagus is usually single—unlike the anterior vagus, which often has multiple trunks. The posterior vagus is mobilized with a right-angle clamp, and a 2- to 3-cm segment is excised between ligatures or clips.

The lower 6-7 cm of the esophagus is cleared of all nerve trunks in order to complete the vagotomy.

Thoracic approach

The thoracic approach (thoracotomy or thoracoscopy) to vagotomy is best suited for patients who have had previous vagotomy or gastric surgery where adhesions are likely to be present in the abdomen. It is applicable only to TV; selective vagotomy (SV) and highly selective vagotomy (HSV) cannot be performed through the thoracic approach.

The patient should be in a right lateral position (ie, with the left side up). The procedure can be performed by taking a transthoracic approach and by using a left eighth or ninth intercostal space anterolateral incision. The left lung is retracted forward. The parietal pleura of the mediastinum is opened vertically behind the esophagus, and the esophagus is mobilized and looped with a soft sling or drain (eg, Penrose). Closure is with an intercostal drain.

The main vagal trunks are dissected and looped as described above. The hepatic branch of the anterior vagus and the celiac branch of the posterior vagus are identified and carefully preserved; only the anterior and posterior gastric nerves of Latarjet (below the origins of the hepatic and celiac branches) are divided.

In current practice, SV is almost never performed. TV and SV denervate the pylorus and antrum and are always combined with pyloric disruption (dilatation, pyloromyotomy, or pyloroplasty) or gastric bypass (gastrojejunostomy).

The main vagal trunks are dissected and looped as described for TV. The hepatic branch of the anterior vagus and the celiac branch of the posterior vagus are identified and carefully preserved; the anterior and posterior gastric nerves of Latarjet (which lie about 1-2 cm from the lesser curvature) are also identified and carefully preserved.

The greater curvature of the stomach is retracted downward and to the left. The anterior layer of the lesser (gastrohepatic) omentum is incised close to the lesser curvature, with care taken not to injure the vascular arcade formed by the left and right gastric vessels and the anterior gastric nerve of Latarjet.

Branches of nerves and vessels (which travel together) going toward the stomach wall are ligated and divided in bits and pieces from proximal to the cardia to the incisura angularis (which lies on the lesser curvature about 6-7 cm proximal to the pylorus). At least three terminal branches (crow's foot) of the anterior gastric nerve of Latarjet, which supply the antrum and the pylorus, must be identified and preserved. This dissection is kept as close to the stomach as possible.

The greater (gastrocolic) omentum is divided 1-2 cm from the greater curvature, with care taken not to injure the vascular arcade formed by the left and right gastroepiploic vessels, and the lesser sac (behind the stomach and in front of the pancreas) is entered.

The stomach is turned upward and to the right, and its posterior surface is exposed.

The posterior layer of the lesser (gastrohepatic) omentum is then incised close to the lesser curvature, with care taken not to injure the vascular arcade formed by the left and right gastric vessels and the posterior gastric nerve of Latarjet.

Branches of nerves and vessels (which travel together) going toward the stomach wall are ligated and divided in bits and pieces from proximal to the cardia to the incisura angularis (which lies on the lesser curvature about 6-7 cm proximal to the pylorus). At least three terminal branches (crow's foot) of the posterior gastric nerve of Latarjet, which supply the antrum and the pylorus, must be identified and preserved. This dissection is kept as close to the stomach as possible.

The lower 6-7 cm of the esophagus is cleared of all nerve branches. A posterior gastric branch of the right vagus, the criminal nerve of Grassi (which traverses to the left and supplies the cardia and the fundus of the stomach), is looked for and divided. The main vagal trunks that had been looped earlier are carefully preserved.

To summarize, in HSV, only nerve branches to the esophagus, cardia, fundus, and corpus are divided. The main (right and left) vagal trunks, the celiac and hepatic branches, the anterior and posterior gastric nerves of Latarjet, and at least three terminal branches of the anterior and posterior gastric nerves of Latarjet, which supply the antrum and the pylorus, are all preserved.

The bared lesser curvature may be reperitonealized by closing the anterior and posterior layers of the lesser omentum. Alternatively, it can be covered with omentum. Some surgeons, however, leave it bare as it is.

Vagotomy can be performed laparoscopically or robotically. Procedures that can be performed laparoscopically include the following[10, 11, 12, 13] :

• Bilateral TV
• Anterior HSV
• Posterior TV and anterior seromyotomy
• Posterior TV

Excised vagal trunks should be sent for histopathologic examination to confirm that both vagi have been divided.

Postoperative care is guided more by associated pyloric disruption or gastric bypass than by vagotomy. The nasogastric tube may be removed at the end of operation. Oral fluids can be started the same evening or the next morning after HSV or 2-3 days after TV (because of the associated pyloroplasty or gastrojejunostomy).

Intraoperative

Complications that may occur during the procedure include the following:

• Injury to the inferior phrenic vein and the left hepatic vein during the division of the left triangular ligament
• Injury to the left lateral segment of the liver while it is being retracted
• Injury to the short gastric vessels and the spleen, especially its upper pole, during the mobilization of the esophagus
• Injury to the wall of the esophagus during mobilization and looping - The tear can be repaired with interrupted sutures of 3-0 polyglactin and reinforced with mobilized fundus of the stomach or a vascularized flap of omentum; a drain should be placed in such cases
• Inadvertent dissection and mobilization of the esophageal muscle fibers that are mistaken for the fibers of the anterior vagus nerve
• Injury to the arcade of vessels along the lesser curvature 

Postoperative

Some of the postoperative complications are due not to the vagotomy per se but to the associated pyloric disruption or gastric bypass.

Immediate postoperative complications may include the following:

• Lesser-curvature necrosis resulting from its inadvertent devascularization (in HSV)
• Delayed gastric emptying because of gastric denervation and atony
• Postvagotomy diarrhea because of intestinal denervation (SV and HSV cause less diarrhea than TV)
• Suture line (pyloroplasty) or anastomotic (gastrojejunostomy) leak
• Dumping because of associated pyloric disruption
• Bile reflux (more with gastrojejunostomy than with pyloroplasty)

Long-term complications may include the following:

• Incomplete vagotomy resulting in recurrent ulcer - Management includes medical treatment with H2-receptor antagonists (H2RAs) and proton pump inhibitors (PPIs), revagotomy (preferably via the thoracic approach), or antrectomy
• Anastomotic ulcer (after gastrojejunostomy)
• Increased incidence of cholelithiasis due to denervation of the gallbladder in TV (not in SV and HSV)
• Carcinoma of the stomach several (>20) years after gastrojejunostomy, which causes bile reflux, chronic gastritis, and intestinal metaplasia in the gastric mucosa