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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_670_Библиотеки_им_академика_М_И_Перельмана
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VAGOTOMY
Over the past several decades, with increased understanding of the pathophysiology of duodenal ulcer disease, the trend
in management gradually evolved from a reliance on gastric ablation, to vagotomy, and then to the pharmacologic con-
trol of acid now finally to the eradication of
Helicobacter pylori
. Today the need for performing a vagotomy is infre-
quent. However, occasionally vagotomy will still be indicated. Recently laparoscopic techniques have been introduced;
therefore, the surgeon now has the option of performing a vagotomy open or via the laparoscope.
Esophagus
Anterior (left) vagus n.
“Criminal” nerves of Grassi, to fundus
Posterior (right) vagus n.
Pylorus
Hepatic branch
Celiac branch
Anterior
and
posterior
nerves of
Latarjet
“Crowʼs foot”
Stomach
1
4 Atlas of Gastrointestinal Surgery: The Stomach
Truncal
The three basic types of vagotomy are truncal, selective, and
parietal cell. The truncal vagotomy divides the anterior and posterior
trunks along the esophagus just above the gastroesophagael junction,
generally before the hepatic and celiac branches are given off (2). A
selective vagotomy is performed by dividing the anterior and poste-
rior trunks,
celiac branches arise (3). In contrast, the parietal
distal
to the point where the hepatic and
Posterior
vagus n.
cell vagotomy does not divide either main
vagal trunk and leaves both nerves of Latarjet
in place. The many branches of both main
vagal trunks and both nerves of Latarjet, which
are given off to the fundus and body of the stom-
ach, are individually divided (4). The more distal
branches to the antrum and pylorus are left intact.
Anterior
vagus n.
2
Hepatic
branch
Celiac
branch
Selective
Parietal cell
Anterior
and
posterior
nerves of
Latarjet
3
4
Truncal Vagotomy
Operative Indications
Until the introduction of parietal cell vagotomy, truncal vagotomy was the most commonly performed type of vagotomy. It
is easy to perform and takes a relatively short time, and most surgeons feel comfortable with the ability to divide both vagal
trunks. Its prime indication is to decrease acid output in the management of peptic ulcer disease. However, knowledge of
the role
Today most peptic ulcer disease can be controlled pharmacologically. Some surgeons have felt that truncal vagotomy also has
a role in the management of gastroesophagael reflux, generally in combination with an antireflux procedure. When a truncal
vagotomy is performed, it is necessary to perform a drainage procedure. Dividing the vagal trunks results in denervation of
the antral pyloric pump/valve mechanism and leads to gastric stasis and gastric ulceration in a substantial number of patients.
Therefore, either a gastrojejunostomy, pyloroplasty, or gastric resection has to be added to truncal vagotomy.
Helicobacter pylori
plays in the pathogenesis of peptic ulcer disease has substantially decreased the role of surgery.
Operative Technique
Truncal vagotomy is usually performed through an upper midline incision. A
self-retaining retractor suspended from a frame attached to the operating room
table, elevating both costal margins, greatly facilitates exposure. The triangular
ligament can be taken down, allowing retraction of the left lobe of the liver
medially. This often is not necessary, and some surgeons prefer to have the left
lobe of the liver merely retracted in a cephalad direction. The serosa overlying
the esophagus is opened, and the esophagus is mobilized by a combination of
blunt and sharp dissection.
6 Atlas of Gastrointestinal Surgery: The Stomach
The esophagus is then encircled with a small Penrose drain, with the aid of a gooseneck clamp (1). When the esopha-
gus is mobilized and encircled with a Penrose drain, if the posterior vagus is not adherent to the posterior wall of the
esophagus, as is frequently the case, it often is not included in the Penrose drain (2). However, when the posterior
vagus is adherent to the posterior wall of the esophagus, it is included in the Penrose drain (3). The posterior vagus is
generally larger than the anterior vagus, and, in my experience, easier to find. However, because it often is not adherent
to the posterior wall of the esophagus, it probably is more frequently overlooked and missed. The anterior vagus is best
identified by retracting caudally with the Penrose drain and feeling for the “violin string” created by placing the anterior
vagus on stretch (4).
Esophagus
Gallbladder
Anterior vagus n.
Liver
Stomach
Duodenum
1
Nasogastric tube
Truncal Vagotomy 7
Posterior
trunk
Both
Anterior
trunk
only in
trunks in
Penrose
drain
Penrose
drain
2
3
Anterior
vagus n.
Posterior
vagus n.
4
8 Atlas of Gastrointestinal Surgery: The Stomach
Esophagus
Distal
ligaclip
When the anterior vagus is identified, a segment is isolated, lig-
aclips are placed, and the segment is resected (5, 6). The pos-
Anterior
trunk
terior vagus is identified either by palpating the posterior aspect
of the esophagus and feeling a tense band while retracting the
stomach caudally, or, more frequently, by finding it posterior-
Stomach
ly between the right and left crura of the diaphragm, usual-
ly in areolar tissue just medial to the right crux. The poste-
rior vagal trunk is always quite large and unmistakable when
it is found. If a large trunk is not found posteriorly, one
must continue to search until it is found.
5
Portion of
trunk
resected
6
Truncal Vagotomy 9
The posterior vagus is also ligaclipped proximally and distally, and a segment excised (7). Both segments should be
sent for frozen section to confirm that both trunks removed consist of nerve fibers. It is important also to feel for addi-
tional nerve fibers not contained in the main anterior and posterior vagal trunks (8). The anatomy is quite variable, but
in a substantial percentage of patients other nerve fibers are contained in vagal slips that are not within the two main
trunks. Only when additional fibers around the entire circumference of the esophagus have been divided is the vago-
tomy complete (9).
Minor vagal
fibers
Posterior trunk
divided
Anterior trunk
divived
7
Anterior
and
posterior
trunks
divided
Skeletonized
esophagus
8
9
Selective Vagotomy
Operative Indications
Selective vagotomy is performed infrequently today. Its advocates in the past thought that preserving the celiac and hepat-
ic branches decreased the long-term morbidity of vagotomy. Indirect evidence suggested that gallstone formation and diar-
rhea were complications that accompanied truncal vagotomy. In an attempt to decrease these two complications, selective
vagotomy was developed to preserve the hepatic and celiac branches. Evidence to support the thesis that these compli-
cations are more frequent with truncal than with selective vagotomy is sparse, and prospective randomized studies have
failed to confirm substantial benefit. Nevertheless, some studies have demonstrated that incomplete vagotomy is less fre-
quent with selective vagotomy than with truncal vagotomy. The probable reason for this is the need to more carefully dis-
sect out the vagal trunks and identify the anatomy with selective vagotomy than with truncal vagotomy, thus more frequent-
ly leading to a complete vagotomy.
Operative Technique
The initial steps of selective vagotomy are identical to those of a truncal vagotomy.
The operative procedure is generally performed through an upper midline incision.
The use of a self-retaining retractor on both costal margins suspended from a frame
attached to the operating table is of great aid in exposure. The esophagus is
exposed by opening the serosa over its anterior surface. With blunt and sharp dis-
section, the esophagus is mobilized and encircled with a Penrose drain. Often the
posterior vagus, which may be in closer relationship to the right crux of the
diaphragm than to the esophagus, is not included in the Penrose drain. The anteri-
or vagus is carefully dissected from the esophagus down to the stomach, and the
small hepatic branch identified. Ligaclips are placed on the vagal trunk below the
Posterior
vagus n.
Selective Vagotomy 11
Esophagus
takeoff of the hepatic branch, and a segment of
nerve is resected and sent for frozen section (1).
Anterior
vagus n.
Hepatic branch
1
Celiac branch
Stomach
The posterior vagal trunk is then dissected out
down to the point where it gives off the celiac
axis branch. Often the celiac branch is actually
larger then the posterior vagal trunk that continues
on as the nerve of Latarjet.
The vagal trunk is doubly clipped below the takeoff of the
celiac branch, and a segment is removed and sent for frozen
section confirmation (2).
Hepatic branch
of anterior vagus n.
of posterior vagus n.
and
celiac branch
preserved
2
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