Vagotomy Technique

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