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12 Atlas of Gastrointestinal Surgery: The Stomach
Minor vagal
fibers
divided
The esophagus is then skeletonized circumferentially to divide
other vagal slips not included in the two main trunks (3).
3
If this dissection is carefully performed, incomplete
vagotomy will be rare (4).
Completed
selective
vagotomy
4
Parietal Cell Vagotomy
Operative Indications
For the past decade parietal cell vagotomy has been the operation of choice for most experienced alimentary tract surgeons
for uncomplicated duodenal ulcer disease, when surgical intervention is required. Today most ulcer disease can be con-
trolled by the eradication of
closing the perforation. Attempts to use parietal cell vagotomy with gastrotomy and dilatation of a partially obstructed
pylorus for pyloric channel ulcers have generally met with failure. The advantage of a parietal cell vagotomy in the treat-
ment of peptic ulcer disease is that it does not require a gastric resection or a drainage procedure. Even though long-term
morbidity from antrectomy, pyloroplasty, and gastrojejunostomy is low, it does exist and is a disadvantage of truncal or
selective vagotomy. With parietal cell vagotomy, satisfactory long-term control of duodenal ulcer disease can be achieved,
with virtually no long-term morbidity. It has been less successful for gastric ulcer disease.
Helicobacter pylori
. Some have performed parietal cell vagotomy for perforated ulcers after
Operative Technique
Parietal cell vagotomy is performed through an upper midline incision. Retraction
of both costal margins with self-retaining retractors suspended from a frame
attached to the operating table is very helpful.
14 Atlas of Gastrointestinal Surgery: The Stomach
The greater curvature of the stomach is
Anterior n.
of Latarjet
Pylorus
Esophagus
1
6 cm
“Crowʼs foot”
Stomach
Peritoneum
incised
grasped with Babcock clamps and
retracted in a caudal and left lateral
direction. Generally this allows for an
easy identification of the anterior
nerve of Latarjet, running in the less-
er omentum along the lesser curvature
of the stomach. The anterior nerve of
Latarjet is carefully preserved, dividing
each individual branch given off by the
nerve of Latarjet and passing on to the
lesser curvature of the fundus and body
of the stomach. The dissection is started
just proximal to the large “crow’s foot” that
the nerve of Latarjet creates as it splays out
onto the antrum of the stomach (1).
If the anatomy of the “crow’s foot” is not clear, one can pick the starting
point for the dissection by measuring 6 cm along the lesser curvature
from the pylorus. The serosal surface of the anterior leaf of the less-
er omentum is opened, and each individual neurovascular bundle
passing on to the lesser curvature of the stomach is divided. This
Anterior n.
of Latarjet
maneuver can be accomplished by exposing the neurovascular
pedicle, tying the pedicle closest to the nerve of Latarjet with a 4-
0 silk (being careful not to injure the main nerve), placing a Crile
clamp on the pedicle adjacent to the lesser curvature, and
dividing the nerve and vessel (2).
Neurovascular
bundles
divided along
lesser curvature
2
Parietal Cell Vagotomy 15
Esophagus
encircled with
Penrose drain
Alternative
Clips on
neuro-
3
vascular
bundles
Anterior n.
of Latarjet
Divided
neurovascular
bundles
The neurovascular tissue held by the Crile clamp is then lig-
ated with a 4-0 silk.
An alternative means is to use small ligaclips (inset). However,
one or more of these ligaclips may come loose, requiring control and risk-
ing injury of the nerve of Latarjet. This dissection is performed distally from the
“crow’s foot” (or 6 cm from the pylorus) up to the gastroesophageal junction and onto the
esophagus. Once the dissection has passed up onto the esophagus, the esophagus is mobi-
lized and encircled with a Penrose drain (3). The dissection should continue in a cephalad
direction on the esophagus for at least 6 cm.
16 Atlas of Gastrointestinal Surgery: The Stomach
Esophagus
Posterior
neurovascular
bundles
divided
Stomach
4
Posterior n.
of Latarjet
Alternative
Exposure through
lesser sac
The same process is then repeated
with the posterior nerve of Latarjet. It
can be performed either anteriorly
through the opening in the lesser
omentum created by dividing the
branches of the anterior nerve of
Latarjet (4), or by dividing the
greater omentum, retracting the stom-
ach in a cephalad direction, and performing
Posterior
stomach
Greater
omentum
divided
Posterior
neuro-
vascular
bundles
Posterior n.
of Latarjet
5
the procedure through the lesser sac (5). Both
techniques are equally easy to perform; anatomy and thickness of the
lesser omentum often dictate the preferred approach. The clearing of
the lesser curvature of the stomach is best done using small Crile
clamps. The same technique used for the anterior nerve of Laterjet is
used for the posterior nerve. During this procedure all tissue in the
lesser omentum in both the anterior and posterior leafs, including all
branches of both nerves of Latarjet, is divided (inset).
Posterior n.
of Latarjet
Anterior n.
of Latarjet
Stomach
L. Gastric
vessels
Hepatic
and
celiac
branches
preserved
Minor vagal
fibers
divided
“Criminal” n.
of Grassi divided
Parietal Cell Vagotomy 17
It is important to continue the dissection of both vagal trunks
well up onto the esophagus for at least 6 cm. Frequently,
small branches leave both the anterior, and particularly
the posterior, vagal trunks up on the esophagus to
pass on to the fundus and body of the stomach. If
these branches are not divided (6), the parietal
Anterior and
posterior nn.
of Latarjet
“Crowʼs foot” preserved
cell vagotomy will be incomplete. Because of the
risk of lesser curvature perforation, which has been
reported on two or three occasions, some surgeons
reperitonealize the lesser curvature of the stomach
with a series of Lembert sutures. However, this compli-
cation occurs with such great rarity, probably as a result of
direct injury to the lesser curvature with clamps, that most sur-
6
geons believe it is unnecessary.
Laparoscopic Vagotomy
Operative Indications
Laparoscopic vagotomy is a minimally invasive technique that provides an alternative to traditional open vagotomy
procedures. Its indications are similar to those of open parietal cell vagotomy. Prior upper abdominal surgery may
preclude its use.
Operative Technique
After the induction of general anesthesia, the patient is placed in the supine posi-
tion, or alternatively in the lithotomy position with the surgeon between the
patient’s legs. The patient should be placed in steep reverse Trendelenburg posi-
tion. A 30˚ telescope is placed in a standard supraumbilical position. Four other
ports (10 to 12 mm) are placed. The superior right subcostal port is used to
retract the left lobe of the liver. The two left-side ports are for retraction of the
stomach. The inferior right port is the primary port for dissection. After complete
laparoscopic examination of the abdominal cavity, a liver retractor is placed under
the left lobe of the liver to expose the gastroesophagael junction. The stomach
should be grasped firmly and retracted to the left caudally, putting tension on the
gastroesophageal junction. A large-bore Maloney dilator or endoscope should be
passed into the stomach to assist in displacing the body of the stomach down-
ward. Using the cautery hook or scissors, the peritoneum over the esophagus is
opened carefully to avoid injury to the anterior vagal trunk (1).
Liver retracted
Laparoscopic Vagotomy 19
Peritoneum
opened
over
esophagus
The esophagus is retracted to the
Anterior vagal trunk
1
Stomach
left with a blunt retractor, expos-
ing the posterior vagal trunk (2).
This maneuver may require
pulling the dilator back into the
proximal esophagus. The posteri-
or vagus can then be doubly
clipped and divided (3).
Maloney
dilator
Anterior
and
posterior
vagal
trunks
Esophagus
retracted with
closed grasper
Posterior
trunk divided
between clips
2 3
20 Atlas of Gastrointestinal Surgery: The Stomach
Divided
posterior
trunk
Anterior
and
posterior nn.
of Latarjet
Vessel
loop
Branches of anterior n. of Latarjet
divided between clips
4
“Crowʼs foot”
After dividing the posterior trunk, the anterior trunk is preserved
and retracted to the right with a vessel loop exposing the nerve of
Latarjet and its numerous branches to the anterior gastric wall (4).
These small branches are doubly clipped and divided. The fibers are
5
divided until reaching the area of the “crow’s foot,” at the junc-
tion of the gastric body and antrum (5). Finally, the multiple
small vagal fibers from the anterior trunk location high on the ante-
rior wall of the stomach and esophagus should be divided with
cautery by retracting the stomach laterally (6). This operative pro-
cedure results in division of the posterior vagal trunk, with preserva-
tion of the anterior vagal trunk, or nerve of Latarjet. The small nerve
branches from the anterior vagus to the parietal cell-containing portion
of the stomach are divided. The operation is thus a combination of pos-
terior truncal and anterior parietal cell vagotomy.
PYLOROPLASTY
Pyloroplasties are performed primarily as drainage procedures following vagotomy or for pyloric stenosis. In addition,
pyloroplasty is performed when truncal vagotomy is a part of another operative procedure not related to duodenal ulcer
disease. One such example is esophagectomy, where the vagotomy is incidental. The most frequently performed pyloro-
plasty is the Heineke-Mikulicz, which is carried out by opening the pylorus in a horizontal fashion (1) and closing it ver-
tically (2). This results in a shortening, but widening, of the pylorus. It destroys the pylorus muscle and renders the pylorus
sphincter incompetent.
Stomach
Heineke-Mikulicz
Pancreas
Duodenum
1
2
A pyloromyotomy is performed in infants with hypertrophic pyloric stenosis and in adults, with a normal pylorus and
duodenum, when a vagotomy is performed during esophagectomy. In this operative procedure the serosa and muscular lay-
ers are divided, but the mucosa is left intact (3). To ensure that any defect in the mucosal layer does not leak, some sur-
geons cover the pyloromyotomy with omentum (4).
Pyloromyotomy
3 4
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