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198
8.2 Posterior Truncal Vagotomy and Denervating Anterior Linear Strip Gastrectomy
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Fig. 8.2.1 The posterior truncal vagotomy (a) can be combined with
various procedures for anterior proximal selective vagotomy: Standard
anterior proximal selective vagotomy with isolated division of the neu-
rovascular bundles of the anterior vagal branches (b), anterior seromy-
otomy down to the mucosa (c), linear resection of the anterior wall of the
stomach with endo-linear cutter (= anterior linear strip gastrectomy) (d).
d
1 posterior vagal trunk
2 anterior vagal trunk
3 Grassi’s “criminal” nerve
4 hepatic branch of anterior vagal trunc
5 Latarjet nerve (crow’s foot)
6 celiac branch of posterior vagal trunk
7 gastric branches of anterior vagus nerve
Position of the Operating Team (Fig. 8.2.3)
The surgeon stands between the patient’s legs. The first assistant stands to the left, the second assistant to the right of the
patient. We favor use of a reverse Trendelenburg position with
the patient rolled to a right lateral decubitus position. The use of
two monitors to the right and left of the patient at shoulder
Position of the Operating Team
Fig. 8.2.2 Posterior truncal vagotomy with anterior linear strip
gastrectomy. Positioning. Place the patient in a reverse Trendelenburg
position with one arm extended and the legs spread apart.
199
level is convenient. The use of 30−45° flexible optic is recommended. The surgeon works with both hands through the two
12-mm trocars, the first assistant guides the camera and assists
via the 5-mm trocar, for example, with grasping forceps, the
second assistant displaces the left lobe of the liver with a retractor or swab.
Insufflator
1
st
Assistant
Monitors
Fig. 8.2.3 Posterior truncal vagotomy with
anterior linear strip gastrectomy. Position of
the operating team and equipment.
2nd Assistant
Irrigation/
Suction device
Electrocautery unit
OR nurse
Surgeon
Instrument table
200
8.2 Posterior Truncal Vagotomy and Denervating Anterior Linear Strip Gastrectomy
Trocar Placement (Fig. 8.2.4)
Complications
Intraoperative Complications
The possible complications are comparable with those of other
open and laparoscopic vagotomytechniques. An insufficiency of
the staple suture resulting from a defective magazine has been
reported (Morlang et al. 1995). Injuries to neighboring organs
such as esophagus, spleen, and liver are in principle possible.
We consider the risk of a stomach perforation during the resection of the anterior stomach wall to be extremely low. Injuries to
the anterior vagal trunk , the hepatic branches, and the anterior
nerve branches of the gastric antrum are possible. Injuries to the
pleura in the course of posterior truncal vagotomy as well as
general thermal damage must also be considered. Depending
on the complications the indications for the—otherwise not
usual—practice of placing a drain at the end of the operation
should be generous.
Corrective action: An esophagus perforation, which when suspected can be diagnosed by intraoperative endoscopy with the
help of insufflation of air or methylene/blue application, can be
closed laparoscopically using simple interrupted sutures tied
either intra- or extracorporally when the surgeon is experienced in suture techniques. Otherwise it must be converted
to open operation. The suture should always be covered by a
fundoplication (anterior hemifundoplication). A renewed test
for leakage is recommended.
Minor injuries to the spleen can be managed laparoscopically by
infrared or electrocoagulation, possible in combination with
hemostyptic agents. Otherwise a laparoscopic or, after conver-
sion, an open splenectomy is required.
Hemorrhages detected intraoperatively from the esophageal
branches or the lesser omentum can usually be adequately
stilled with an ultrasonic scalpel or with clips. Bleeding from
veins of the diaphragm should be managed with clips. The use
of the ultrasonic scalpel is not recommended for the frequently
observed minor bleedings of the staple suture, electrocoagulation should also be avoided in favor of clips (see Fig. 8.2.16).
In cases of insufficiencies of the staple suture it can be oversewn
endoscopically or close d with individual clips or the linear stapler (additional application).
Postoperative Complications
T3
T5
T4
T1
Fig. 8.2.4 Posterior truncal vagotomy with anterior linear strip
gastrectomy. A total of five ports is required. After establishing the
pneumoperitoneum with a paraumbilically placed Veress needle, this incision is extended for a 10-mm trocar for the 30° or 45° optics (T1). The remaining working trocars are inserted under laparoscopic vision. From the
surgeon’s view the semicircular array of ports consists to the left of optics
trocar of a 12-mm working trocar (T4) and a 10-mm trocar (T5) for the retractor to elevate the left lobe of the liver. To the right are a second 12mm working trocar (T2) and a 5-mm working trocar (T3). The endo-linear
cutter can later be inserted through the two 12-mm trocars at an ideal
angle to the various segments of the small curvature of the stomach
(Figs. 8.2.11 to 8.2.13 ).
Alternative: open laparoscopy
drome) are very rare and, if necessary, can be treated symptomatically. A pylorus stenosis resulting from an inadvertent total
truncal vagotomy can b e dilated endoscopically using a balloon
catheter.
T2
There are no reports of postoperative complications in the literature. In an already released patient we observed an Hb-active, intraluminal hemorrhage from the staple suture on the 8
postoperative day. It was controlled endoscopically by injection
of fibrin.
In case of a secondary hemorrhage with a pronounced decrease
in Hb and the corresponding sonographic findings, a laparo-
scopic re-intervention to stop the bleeding can be undertaken
when the patient is stable and the surgical team highly experienced. The indications for conversion should be generous. If
the patient has an unstable circulation a direct laparotomy is required. When an intraluminal hemorrhage (staple suture, ulcer)
is suspected, endoscopy and an attempt to stop the bleeding endoscopically are called for.
Under consideration of the clinical situation, smaller hemorrhages from the spleen and liver may only need close monitoring when a drainage is present.
Postoperative emptying disorders (atony, post-vagotomy syn-
Late Complications
th
Recurrent ulcers or persisting duodenal ulcers have only been
described in one case (< 1%) (Gomez-Ferrer et al. 1996) and are
first treated conservatively; a reinfection with Heliobacter pylori
must always be considered. When searching for the cause, a
control gastric acid analysis and determination of the serum
gastrin level should be made.
Results
A sufficient suppression of the basal and maximal acid output
(BAO: 50−80%, MAO 60−80%) (Meyer et al. 1995; Gomez-Ferrer
et al. 1996) have been determined in various studies. Although
long-term results from larger patient collectives are not yet
available, the currently evaluated data are promising with 98−
100% having a Viseck score of I to II.
Results
201
Step-by-Step Procedure
(Figs. 8.2.5 a-d)
I Technical preparations
1. Adjust the electrocautery unit to an average setting or corresponding setting for the ultrasonic scalpel.
2. Connect the aspirator/irrigator set.
3. Prepare the gastroscope.
4. Start the video and recording unit.
II Establishing the pneumoperitoneum
1. Select pressure levels according to patient’s size, age and
weight (10−14 mm Hg).
2. Connect all instruments required for operation.
3. Make a paraumbilical skin incision for the Veress needle and
optic trocar.
4. Insert the Veress needle.
5. Perform safety tests: injection, aspiration, “slurp”, manometer, and rotation tests (see chapter 2.2).
Alternative: open laparoscopy.
III Laparoscopy
1. Introduce the trocar for the laparoscope paraumbilically.
2. Insert the 30−45° optic.
3. Place patient in 30° anti-Trendelenburg position.
4. Insert the four instrument trocars in the left and right middle
or upper abdomen under laparoscopic visualization.
5. Examine the abdominal cavity.
6. Tilt the operating table 30° to the right.
7. Expose the esophageal-gastric junction and the anterior wall
of the stomach. If necessary displace the left lobe of the liver
after division of the left triangular ligament, exposed by tension on the greater curvature of the fundus or body to the
left.
8. Divide the pars flaccida of the lesser omentum superior to the
hepatic branches (1), the phrenico-esophageal membrane (2)
and the gastrophrenic ligament (3) with exposure of the right
crus of the diaphragm and the terminal esophagus (4) in their
right anterolaterodorsal courses (Fig. 8.2.5a, b). Care must
be taken to preserve an aberrant left hepatic artery, which is
found in 10% of cases.
9. Identify, mobilize, and excise the posterior vagal branch (5)
for a length of about 2 cm (Fig. 8.2.5b).
10. Identify the crow’s foot (6) (Fig. 8.2.5b).
11. Form a fold of all layers of the anterior wall of the stomach (7)
including the first branches of the crow’s-foot (Fig. 8.2.5c).
12. Strip-like resection of the anterior wall of the stomach from
caudal to cranial about 1.5 cm parallel to the small curvature
(8) (Fig. 8.2.5c).
13. Complete the resection at the upper anterior wall of the fun-
dus (include the criminal branch) to the left next to the
esophageal junction (9) (Fig. 8.2.5c).
14. Recover the tube like piece of stomach (10) resected through
a 12-mm trocar (Fig. 8.2.5d).
15. Check the staple sutures for leaks and absence of blood (11)
under intraluminal endoscopic vision with insufflation of air
(Fig. 8.2.5d).
16. Control bleedings (12) if necessary (Fig. 8.2.5d).
17. Remove the trocars under laparoscopic visualization. Fascial
closure of the incisions for the instrument trocars (> 5 mm)
and laparoscopic control of the closures for absence of leakage and bleeding.
18. Deflate the pneumoperitoneum, extract the laparoscope tro-
car and fascial closure of the paraumbical incision.
19. Skin sutures. The gastric tube is left in place of 12−24 hours.
Operative Technique
2
3
1
!
Fig. 8.2.5
a Access to esophageal-gastric junction
1 Divide the cranial pars flaccida put under tension by traction on the
greater curvature. Note: preserve the hepatic branches (!)
2 Divide the phrenico-esophageal membrane.
3 Divide the gastrophrenic ligament.
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5
4
6
1
b Posterior truncal vagotomy
4 Expose the right crus of the diaphragm and the terminal esophagus.
5 Expose the posterior vagus branch for resection.
6 Identify the anterior antral branch (crow’s-foot).
202
8.2 Posterior Truncal Vagotomy and Denervating Anterior Linear Strip Gastrectomy
!9
1,5 cm
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8
c Anterior linear strip gastrectomy
7 Create a fold including all layers of the anterior wall of the stomach.
8 Linear resection of the wall of the stomach.
9 Completion of gastric wall resection at the upper posterior wall of the fun-
dus including Grassi’s criminal nerve.
11
12
11
11
11
10
d Removal of resected material and insufflation test for leakage and
bleeding
10 Recovery of resected material
11 Control of the staple sutures for absence of leakage and blood by gastros-
copy, air insufflation, and saline. The pylorus is compressed to prevent air
from escaping distally.
12 Bleeding from the staple lines are managed by clips.
T2
T4
Fig. 8.2.6 Posterior truncal vagotomy with anterior linear strip
gastrectomy. Mobilization of the left lobe of the liver.
For access to the hiatus, the left liver lobe must be elevated with an liver
retractor or swab (T5). If the left lobe is large its mobilization may be nec-
essary. For this the left triangular ligament and the appendix fibrosa is
divided with the ultrasonic scalpel or electric scissors under tension from
lateral to medial using a grasper. The ligament is divided close to the liver
in order to avoid injury, especially to the left diaphragmatic vein.
T4
T2
T3
Fig. 8.2.7 Posterior truncal vagotomy with anterior linear strip
gastrectomy. Lateral approach to the hiatus.
After the left lobe of the liver has been elevated, preferably with a swab
held in a forceps, the view and approach to the hiatus and gastroesophageal junction are clear. Under tension of the cranial pars flaccida the
lesser omentum is opened while preservation the hepatic branches. For
this the left crus of the diaphragm is exposed as a landmark. On account
of the small transverse arterial and venous branches complete control of
bleeding is essential (ultrasonic scalpel, electrocoagulation, clips).
T4
Operative Techniques
203
T3
T2
Fig. 8.2.8 Posterior truncal vagotomy with anterior linear strip
gastrectomy. Hiatal dissection.
After space has been created between the right limb of the diaphragm
and the right lateral esophagus, mainly by blunt dissection, the phrenicoesophageal membrane is divided. For this the gastroesophageal junction
is lifted with forceps. It is advantageous to continue the preparation on
the left side of the esophagus and to divide the gastrophrenic ligament
under tension at the apex of the fundus at this stage in order to be able to
reach the posterior wall of the fundus during the later linear gastric resec-
tion.
T2
T3
T2
Fig. 8.2.9 Posterior truncal vagotomy with anterior linear strip
gastrectomy. Posterior truncal vagotomy.
The esophagus in the hiatus is displaced anterolaterally to the left and the
right laterodorsal wall of the esophagus as well as the mediastinum and
hiatus in this region are exposed. The posterior vagal trunc usually courses
along the wall of the esophagus but may also run separately through the
hiatus. There is a wide variety in thickness of the nerve. After identification the nerve is isolated over a longer course, grasped with forceps, and
resected over a length of about 2 cm with the ultrasound scalpel or between two clips. In cases of doubt an intraoperative rapid section diagnosis can confirm resection of the nerve.
Fig. 8.2.10 Posterior truncal vagotomy with anterior linear strip
gastrectomy. Anterior linear strip gastrectomy. Anterior vertical gastric resection.
In anterior vertical gastric resection, a closed, tube-like complete stomach
wall is resected. The linear gastrectomy with subsequent eversion suture
should ensure that the gastric branches of the anterior vagus nerve passing obliquely through the seromuscular layers of the stomach are
completely divided. Thus, the strip-like gastric wall resection is made
about 1.5 cm from the lesser curvature. Through use of the stapler, the
stomach is not opened at any time.
After identification of the Latarjet’s nerve, a stomach fold is formed using
two forceps which also includes the upper branches of the crow’s-foot, 5
to 7 cm oral to the pylorus.
204
8.2 Posterior Truncal Vagotomy and Denervating Anterior Linear Strip Gastrectomy
T3
T4
T2
Fig. 8.2.11 Posterior truncal vagotomy with anterior linear strip
gastrectomy. Anterior linear strip gastrectomy.
The resection is started at the junction between the body and the antrum
including the first branch of the crow’s-foot. It is important that enough
tissue is included in order to divide the entire wall of the stomach on both
T3
sides of the strip excision. The result is an everted, secure suture with
three staggered staple rows (blue or green magazine). The intramural
anterior vagus branches are completely divided and removed with the resected strip or sleeve of the stomach.
T2
Fig. 8.2.12 Posterior truncal vagotomy with anterior linear strip
gastrectomy.
By stepwise application of the endo-linear cutter the resection is con-
tinued piece by piece about 1.5 cm from the lesser curvature and parallel
to it in a cranial direction. Each segment for stapling is lifted in a folded
manner with a forceps.
T2
Fig. 8.2.13 Posterior truncal vagotomy with anterior linear strip
gastrectomy. Anterior linear strip gastrectomy.
The resection is continued as described in a cranial direction beyond the
apex of the fundus to the posterior wall next to the gastroesophageal
junction. In this way branches of Grassi’s “criminal” nerve and further
vagal branches on the left side of the esophagus are divided so that finally
fundus and body are completely denervated. At the anterior wall of the
fundus care must be taken to stay away from the cardia in order to avoid a
possible stenosis in this region. About 5−7 staple magazines are needed
for the entire resection.
Operative Techniques
205
Fig. 8.2.14 Posterior truncal vagotomy with anterior linear strip
T2
gastrectomy. Extraction of resected strip of anterior gastric wall.
The resected tube shaped gastric strip is removed through a 12-mm trocar.
Fig. 8.2.15 a Posterior truncal vagotomy with anterior linear strip
gastrectomy. Staple line examination.
a Intraoperative gastroscopy is used to inspect the intraluminal aspect of
the staple lines for unsuspected lears and/or bleeding.
T2
T2
T4
Fig. 8.2.15 b Any leak from the air-filled stomach can be detected
extraluminally by simultaneous laparoscopic instillation of saline (insert)
and corrected (simple sutures or linear stapler). In order to avoid the
escape of air into the small intestine, the pylorus is compressed with a
swab. Extraluminal bleeding from the gastric staple lines can also be detected and controlled by laparoscopic means.
206
8.3 Selective Proximal Vagotomy
Bibliography
Bailey RW, Flowers JL, Graham SM, Zucker KA. Combined laparoscopic
cholecystectomy and selective vagotomy. Surg. Lap. Endoscop. 1991;1:45−
49.
Gomez-Ferrer F, Anton V, Llombart A. Regeneración nerviosa en la pared
anterior del estómago despues de gastrotomía y vagotomía posterior en la
rata. Rev. Esp. Enferm. Dig. 1993; 84:85−89.
Gomez-Ferrer F, Balique JG, Azagra S, Bicha-Castelo H, Castro-Sousa F, Es-
palieu P, Rodero D, Estour E. Laparoscopic surgery for duodenal ulcer: First
results of a multicentre study applying a personal procedure. Br. J. Surg.
1996; 83:547−550.
Hannon JK, Snow LL, Weinstein LS. Endoscopic staple assisted anterior
highly selective vagotomy combined with posterior truncal vagotomy for
treatment of peptic ulcer disease. Surg. Laparo. Endosc. 1992; 2:254−257.
Hill GL, Barker MCJ. Anterior highly selective vagotomy with posterior trun-
cal vagotomy: a simple technique for denervating the parietal cell mass.
Br. J. Surg. 1978; 65:707−705.
Katkhouda N, Mouiel J. A new technique of surgical treatment of chronic
duodenal ulcer without laparotomy by videocoelioscopy. Am. J. Surg.
1991; 161:361−364.
Meyer G, Hatz RA, Hüttl TP, Lange V, Schildberg FW (1995). Technik und
Ergebnisse der laparoskopischen Vagotomie beim chronischen Ulcus
duodeni. Zentralbl. Chir. 120:364−372.
Morlang T, Löwenthal S, Umscheid T, Stelter WJ (1995). Laparoskopische
selektive Vagotomie (hintere trunkuläre Vagotomie und vordere lineare
Magenresektion) beim komplizierten Ulcus duodeni. Zentralbl. Chir.
120:373−376.
Mulholland MW, Debas HT (1989). Effects of intramural division of gastric
vagal fibers on stimulated acid production. Am. J. Surg. 157:225−229.
Taylor TV, Gunn AA, Macleod DAD, Mac Lennan I (1982). Anterior lesser
curve seromyotomy and posterior truncal vagotomy in the treatment of
chronic duodenal ulcer. Lancet 1998;2:846−849.
T2
Fig. 8.2.16 Posterior truncal vagotomy with anterior linear strip
gastrectomy. Management of bleeding from the staple lines.
Persistant bleeding from everted suture rows in the air-filled stomach are
easily seen and localized. If they do not subside spontaneously, these
small hemorrhages can be managed by clipping.
8.3 Selectiv e Pro ximal Vagotomy
A. Pier , F . Götz
Objectives and Methods
Selective proximal vagotomy without pyloroplasty is the procedure of choice for managing an uncomplicated duodenal
ulcer that does not respond to nonoperative treatment. It is an
adjuvant procedure in suturing a bleeding proximal duodenal
ulcer or a perforated anterior gastroduodenal ulcer, and in performing an antrectomy (combined operation). In a selective
proximal vagotomy, the vagal fibers of the gastric fundus and
body including the fundic (criminal) branch and the gastroepiploic branch of the anterior vagal trunk are dissected. The hepatic branches, celiac branch, and anterior and posterior antral
branches of the vagal trunk are left intact (see Fig. 8.1.1). In the
presence of a pyloric stenosis, intraoperative dilation of the stenosis or pyloroplasty is indicated. In selective proximal
vagotomy (as in surgical repair of the esophageal hiatus or truncal vagotomy), the esophagus is splinted with a gastric tube or
an endoluminal endoscope for transillumination and orientation of landmarks.
Patient Positioning
(Fig. 8.3.1).
Position of the Operating Team
(Fig. 8.3.2).
The surgeon stands between the patient’s legs. The first assistant stands to the right and the second assistant to the left of
Anesthesia
General anesthesia.
Fig. 8.3.1 Selective proximal vagotomy. Positioning.
Place the patient supine in a reverse Trendelenburg position with one arm
extended and the legs spread apart.
Monitor
nd
2
Assistant
Fig. 8.3.2 Selective proximal vagotomy.
Position of the operating team and
equipment.
Aspirator/
irrigator set
Complications
207
Insufflator
Electrocautery unit
st
Assistant
1
Surgeon
the patient. We recommend a reverse Trendelenburg position
with the patient rolled into a moderate left lateral decubitus
position. The monitor with video recorder and light source is lo-
cated at the patient’s right shoulder. The respirator and the anesthesiologist are off to the left.
The aspirator/irrigator set is placed on the left side of the
patient, as is a second monitor for the first assistant if available.
The insufflator is placed in the first assistant’s visual field. The
OR nurse is standing along the left leg of the patient and the
electrocautery near the right leg. For the techniques described
in the following sections, a 30-degree laparoscope is essential
for better visualization of the operative site.
OR nurse
Instrument table
− Vagal nerve fibers left in place.
− Injury to the anterior vagal trunk.
− Fundic branches left in place.
− Injury to the parietal pleura.
− Pyloric stenosis left untouched.
− Thermal tissue damage from electrocautery.
Corrective action: Injuries to the spleen or esophagus should be
managed via laparotomy.
Non-bleeding tears in the capsule of the liver and seromuscular
defects of the stomach can be managed laparoscopically.
For specific complications see p. 199.
Trocar Placement
(Fig. 8.3.3).
Complications
(See Fig. 8.1.7,p.).
Intraoperative Complications
− Injury to the spleen, esophagus, liver, or stomach.
− Injury to the hepatic branches of the vagus nerve.
− Injury to the celiac branch of the vagus nerve.
− Injury to the antral nerves.
Immediate Postoperative Complications
After laparoscopic selective proximal vagotomy the same complications may occur as after conventional open procedures for
the treatment of a gastric or duodenal ulcer. These include:
− Bleeding
− Necrosis of the stomach wall.
− Peritonitis.
− Mediastinitis.
− Pleural effusion.
− Gastric atony.
− Pyloric stenosis.
− Symptomatic gastroesophageal reflux.
− Recurrent ulcer.