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208
8.3 Selective Proximal Vagotomy
Post-vagotomy syndrome with dysphagia and/or diarrhea is rare
following selective proximal vagotomy. Excessive suture mate-
rial at the operative site may contribute to formation of
granulomas.
Corrective action: Endoscopy can be used to remove intraluminal suture material.
Bleeding
Corrective action: In the presence of clinically diagnosed bleeding and free peritoneal fluid detected via ultrasound, repeat laparoscopy or conventional laparotomy is indicated if the patient
requires a significant transfusion for stabilization. If difficulties
are encountered during a second laparoscopic approach (such
as locating the source of bleeding or using suction), immediate
conversion to laparotomy is indicated.
Note: Repeat, corrective laparoscopy requires the highest level
of surgical skills and expertise.
T4
Necrosis of the Stomach Wall
Partial gastric wall thermal necrosis is generally localized to the
lesser curvature and is produced by electrocautery.
Caution: Using monopolar electrocautery can produce thermal
tissue damage and is usually not through the entire gastric wall
thickness.
Corrective action: Placement of a nasogastric tube and
parenteral feeding are indicated. Usually the lesion will heal
spontaneously. Perform endoluminal endoscopic follow-up ex-
amination if necessary. If the lesion persists or involved the entire gastric wall thickness when the mishap occurred, laparotomy and repair are indicated.
Peritonitis
Immediate conventional laparotomy is indicated in the pre-
sence of suspected or confirmed peritonitis.
Mediastinitis
Injury to the esophagus can result in infection of the mediastinum.
Initially, the infection may remain without clinical symptoms.
Corrective action: Immediate laparotomy, drainage, and repair
are indicated if this complication is suspected.
Pleural Effusion
A pleural effusion may accompany a perforation of the
esophagus in the presence of mediastinitis regardless of
whether the pleura itself is open or not.
Corrective action: First aspirate the pleural effusion and drain it.
If esophageal or gastric leakage is detected, laparotomy is indicated to suture the defect. Fundoplication and placement of a
drain may be necessary (see Fig. 8.3.15 ).
Gastric Atony
Treat with motility agents and place a nasogastric tube.
T5
T3
T2
T1
Fig. 8.3.3 Selective proximal vagotomy. Trocar placement.
A total of five ports is required. Insert a 10.5-mm laparoscope/camera trocar (T1) with a trumpet valve into the abdominal cavity about two finger
breadths above the umbilicus after establishing the pneumoperitoneum.
Then insert four working trocars under laparoscopic vision. Ports T3 and
T5 contain 10.5-mm instrument trocars for various dissection instruments. An additional 5.5-mm instrument trocar at port T4 is inserted to
permit introducing a retractor to lift the left hepatic lobe. We recommend
intraluminal splinting and transillumination of landmarks with a gastroscope. Open trocar placement is an alternative.
Symptomatic Gastroesophageal Reflux
In most cases, preoperatively symptomatic gastroesophageal
reflux was present.
Corrective action: Treat nonoperatively at first. If this is unsuccessful, conventional Nissen fundoplication is indicated.
Late Complications
Pyloric Stenosis
Persistent or recurrent ulcers can lead to pyloric stenosis.
Corrective action: Initiate adequate nonoperative therapy and
careful endoscopic dilation of the pylorus. Where this is unsuccessful or complications occur, surgical intervention is indicated.
Suture Granulomas
The clinical significance of suture granuloma varies.
Corrective action: Endoscopy can be used to remove intraluminal sutures.
Recurrent Ulcer
Ulcers recur in 4−10% of all patients. Contributing factors include the patient’s dietary habits, the surgical technique, and
persistent infection with Helicobacter pylorii. As long as laparoscopic selective proximal vagotomy with a circular esophageal
myotomy remains unfeasible, a higher incidence of recurrence
must be expected.
Corrective action: Nonoperative treatment. Exclude chemical
and toxic factors, and treat infection due to Helicobacter pylorii.
Conventional surgical intervention is indicated in the presence
of a persistent ulcer or complications.
Complications
209
Step-by-Step Procedure
I Technical preparations
1. Adjust the electrocautery unit to an average setting.
2. Connect the aspirator/irrigator set.
3. Prepare an endoluminal endoscope.
4. Start the video and recording unit.
II Establishing the pneumoperitoneum
1. Select pressure levels according to patient’s size, age, and
weight (6−8 mm Hg for children; 10−14 mm Hg for adults).
2. Connect all instruments required for operation.
3. Make a skin incision about two finger breadths above the
umbilicus for the Veress needle and laparoscope/camera tro-
car.
4. Insert the Veress needle.
5. Perform safety tests: injection, aspiration, “slurp,” manometer, and rotation test.
6. Perform insufflation procedure.
Caution: Insufflate infants at 1 l/min maximum.
III Laparoscopy
1. Place nasogastric tube.
2. Insert laparoscope/camera trocar with tapered blunt-tip sty-
let about two finger breadths above the umbilicus directly
through the linea alba.
3. Insert the instrument trocars in the left and right upper abdo-
men under laparoscopic visualization.
4. Explore the peritoneal cavity.
5. Check the diameter of the pylorus (in the presence of an uncomplicated duodenal ulcer).
6. Retract the antrum and body inferiorly.
7. Identify the anterior gastric branch (nerve of Latarjet) and the
crow’s foot.
8. Incise the lesser omentum along the lesser curvature.
9. Completely expose each neurovascular bundle as the dissection progresses caudally.
10. Place two clips on each bundle after coagulation with bipolar
electrocautery and transect between clips.
Caution: Thermal tissue damage can result.
11. Dissect as far as the cardia.
12. Clear the anterior aspect of the esophagus above the GE junction.
13. Prepare and incise the posterior peritoneal attachments with
their neurovascular structures at the cardia.
14. Expose and transect the fundic (criminal) branch at the left
lateral margin of the esophagus. Optional: Perform anterior
fundoplication (see p. , Fig. 8.3.15).
15. Close the serosa of the lesser curvature.
16. If necessary, transect the right gastroepiploic neurovascular
structures.
17. Remove the trocars under laparoscopic visualization.
Caution: Residual bleeding from the trocar incisions may occur.
Operative Technique
2
Fig. 8.3.4 Principles of selective proximal vagotomy.
In selective proximal vagotomy, the gastric branches, the “criminal”
branch, and the gastroepiploic branch are transected. The gastroepiploic
branch is divided along the greater curvature where the gastric antrum
and body join.
The selective proximal vagotomy preserves the two main trunks, the
anterior and posterior antral branches, the hepatic branches, and the
celiac branches. In the presence of pyloric stenosis, pyloroplasty is indicated. As in surgical repair of the esophageal hiatus or truncal vagotomy,
the esophagus is splinted with a large nasogastric tube.
1
1 Anterior and posterior gastric branches
2 Fundic branch
3 Gastroepiploic branch
4 Anterior antral branch
Arrow: Distal end of the incision for dissection along the lesser cur vature
lies superior to the proximal branch of the crow’s foot (see Fig. 8.3.5).
43
210
T5
8.3 Selective Proximal Vagotomy
T4
T3
T2
Fig. 8.3.5 Selective proximal vagotomy. Dissecting along the lesser cur-
vature.
After identifying the course of the cephalad branch of the crow’s foot (of
the anterior antral branches), begin proximal to this level with the dissection along the lesser curvature (see arrow in Fig. 8.3.4). Apply tension to
the stomach inferiorly (port T2), lift the lesser omentum (port T4), and
open the peritoneal membrane with scissors (port T3). Next, pass a
curved grasper through the avascular portions of the anterior connective
tissue and lift out the tissue containing the neurovascular bundle (insert).
T2 Babcock clamp to grasp the stomach
T3 Scissors
T4 Grasper lifting the lesser omentum
T5 Laparoscopic retractor holding the left hepatic lobe
Fig. 8.3.7 Selective proximal vagotomy. Dissection.
Expose the superior portion of the lesser omentum and the perie-
sophageal tissue while preserving the anterior vagal trunk. The dissection
extends past the esophagus to the left in an obliquely cephalad direction.
Fig. 8.3.6 Selective proximal vagotomy. Dissecting along the lesser curvature.
The dissection begins distally and extends from below upwards. Use
bipolar electrocautery (insert) to coagulate the individual neurovascular
structures isolated previously by blunt dissection. Two clips are applied,
one close to the wall of the stomach and the other peripherally, and the
nerve and vascular branches are divided between the clips. Control minor
bleeding with bipolar electrocautery.
Caution: Thermal damage to the lesser curvature can produce necrosis.
T4
T4
Complications
211
T2
Fig. 8.3.8 Selective proximal vagotomy. Dissection of the posterior peri-
toneal sheath.
Beginning at the incisura angularis, the posterior peritoneal sheath of the
lesser omentum containing neurovascular structures is divided. It helps to
retract the body of the stomach inferiorly (port T2). Use a grasper inserted
through port T4 to lift and expose the vascular structures to be ligated.
Then you may clip them as described in Fig. 8.3.6 or ligate them with pre-
tied extracorporeal Roeder knots or intraabdominal surgical knots.
Fig. 8.3.9 Selective proximal vagotomy. Exposing the terminal
esophagus.
Dissecting the lateral and posterior cardia and the esophagus is difficult.
We recommend using a 30-degree angled laparoscope for better visualization of the operative site. Flexible-tipped scissors and graspers are best
in this situation (see Fig. 8.3.3 for key to instrument numbers).
T4
T3
Fig. 8.3.10 Selective proximal vagotomy. Dissecting the fundic branch
(criminal nerve).
The fundic branch is located on the left lateral margin of the esophagus.
Expose it completely and transect it (see Fig. 8.3.3 for key to instrument
numbers).
Fig. 8.3.11 Selective proximal vagotomy. Partial fundoplication.
One surgical option in reducing the risk of gastroesophageal reflux is to
perform a partial fundoplication. Without applying tension, wrap the me-
T5
T2
dial section of the fundus over the distal esophagus and suture it to the
right wall of the esophagus and the right side of the hiatal crus with three
or four interrupted sutures.
Use absorbable suture material (3 × 0, metric 2) 90 cm long. We recommend a slip knot.
T2 Babcock stomach grasper
T3 Needle holder
T4 Laparoscopic retractor (holding left hepatic lobe)
T5 Babcock stomach grasper
212
8.3 Selective Proximal Vagotomy
Fig. 8.3.12 Selective proximal vagotomy. Closing the serosa of the lesser
curvature.
Finally, close the serosa of the lesser curvature with interrupted
seromuscular sutures. Use absorbable suture material (3 × 0, metric 2)
15−20 cm long. We recommend a slip knot secured with an additional
locking knot or surgeon’s knot.
The right gastroepiploic branch of the vagal trunk is contained in the
vascular bundle of the right gastroepiploic vessels. Divide this branch
where the antrum and the body join. Finally, verify hemostasis and place a
suction drain (see Fig. 8.3.3 for key to instrument numbers).
T3
T4
T2
Fig. 8.3.13 Selective proximal vagotomy. Closing the serosa of the anterior peritoneal sheath with surgeon’s knots.
Begin your sutures of the anterior and posterior peritoneal sheath proximally (see Fig. 8.3.3 for key to instrument numbers).
Fig. 8.3.14 Selective proximal vagotomy. Complication: tear in the
esophagus.
Manipulation of the terminal esophagus or a nasogastric tube can tear the
esophagus. If you suspect that a perforation has occurred, inject a dilute
methylene blue solution into the esophagus (see Fig. 8.3.3 for key to in-
strument numbers).
Corrective action: Repair the defect with closely placed interrupted su-
tures, and cover it with a partial fundoplication.
Manage the defect via laparotomy.
Fig. 8.3.15 Selective proximal vagotomy. Managing an injury to the
esophagus.
Repair the defect directly with closely placed interrupted sutures, and
cover it with a classic fundoplication.
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Burge H. Vagotomy. London: Arnold; 1964.
Burge HW, Hutchinson JSF, Longland CJ, McLennan I et al. Selective nerve
section in the prevention of post-vagotomy diarrhea. Lancet 1964; 1:577.
Craig PI, Gillespie PE. Through the endoscope balloon dilatation of benign
gastric outlet obstruction. Birt. Med. J. 1988; 297:396.
Daniel EE, Sarnasa SK. Distribution of excitatory vagal fibres in canine gastric
wall to central motility. Gastroenterology 1976; 71:608.
Delmas J, Laux G. Système nerveux sympathique, vol. 1. Paris: Masson; 1952.
Desmond AM. Selektive proximale Vagotomie. In Burge H, Farthmann EH,
Grassi G, Hedensted SB, Hollender LF, Schreiber HW, Tanner NC. Vago-
tomie, p. 101. Stuttgart: Thieme; 1976.
Dragstedt LR. Section of the vagus nerves to the stomach in the treatment of
peptic ulcer. Ann. Surg. 1947; 126:687.
Dubois F. Vagotomie sélective avec conservation des vaisseaux coronaires.
Nouv. Presse Me d. 1976; 5:2322.
Franckson C. Selective abdominal vagotomy. Acta Chir. Scand. 1948; 96:409.
Helms B, Czametzki HD, Krause N, Jantschulev M, Scharlau U. Technik und
Ergebnisse der laparoskopischen selektiv proximalen Vagotomie. Ver-
dauungskrankheiten 1993; 11:145.
Hill GL, Barker MCJ. Anterior highly selective vagotomy with posterior trun-
cal vagotomy: a simple technique for denervating the parietal cell mass.
Brit. J. Surg. 1978; 65:702.
Holle F, Anderson S. Vagotomy. Berlin: Springer; 1974.
Hollender LF. Pyloroplastik. In Bunge H, Farthmann EH, Grassi G, Hedenstedt
SB, Hollender LF, Schreiber HW, Tanner NC. Vagotomie, p. 49. Stuttgart:
Thieme; 1976.
Hollender LF, Marrie A. Die selektiv proximale Vagotomie. Berlin: Springer;
1978.
Hollender LF, Marrie A. Highly selective vagotomy, vol. 1. Paris: Masson;
1979.
Jackson RC. Anatomic study of vagus nerves with a technique of trans-
abdominal selective resection. Arch. Surg. 1948; 57:333.
Johnston D. Selektive Vagotomie mit Ulkusexzision beim Ulcus ventriculi. In
Becker HD, Lierse W, Schreiber HW. Magenchirurgie, p. 167. Berlin:
Springer; 1986.
Johnston D, Wilkonson AR. Higher selective vagotomy without a drainage
procedure in the treatment of duodenal ulcer. Brit. J. Surg. 1970; 57:289.
Kahwaji F, Grange D. Ulcère duodénal chronique: Traitement par séromyo-
tomie fundique antérieure avec vagotomie tronculaire postérieure. Presse
Med. 1987; 16:28.
Katkhouda N, Mouïel J. A new surgial technique of treatment of chronic
duodenal ulcer without laparotomy by videocoelioscopy. Amer. J. Surg.
1991; 161:361.
Latarjet MA. Résection des nerfs de l’estomac. Bull. Acad. Med. 1922; 87:681.
Mikulicz J. Zur operativen Behandlung des stenosierenden Magen-
geschwürs. Arch. klin. Chir. 1888; 37:79.
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Mouïel J. Actualités digestives médico-chirurgicales, 10
Masson; 1989.
Mouïel J. Katkhouda N. Laparoscopic truncal and selective vagotomy. In
Zucker KA. Surgical Laparoscopy, p. 263. St. Louis: Quality Medical Publishing; 1991.
Mouïel J, Katkhouda N, Gugenheim J, Fabiani P et al. Traitement de l’ulcère
duodénal par vagotomie tronculaire postérieure et séromyotomie antérieure sous vidéolaparoscopie. Note préliminaire avec présentation de film.
Académie de Chirurgie, Paris. Séance du 6 juin 1990. Chirurgie 1990;
116:546.
Nyhus LM. Vagotomy. In Nyhus LM, Wastell C. Surgery of the Stomach and
Duodenum, 4
Oost Vogel HJM, Van Vroonhoven TJMV. Anterior seromyotomy and poste-
rior truncal vagotomy. Technic and early results of a randomized trial.
Neth. J. Surg. 1985; 37:69.
Ramstedt C. Zur Operation der angeborenen Pylorusstenose. Med. Klinik
1912; 8:1702.
Rosati I, Serantoni G, Ciani PA. Extended selective proximal vagotomy: Ob-
servations on a variant technique. Chir. Gastroent. 1976; 10:33.
Sakuramachi S, Kimura T, Harada Y. Experimental study of laparoscopic
selective proximal vagotomy using a carbon dioxide laser. Surg. Endosc.
1994; 8:857.
Sawyers JL. Selective vagotomy and pyloroplasty. In Nyhos LM, Baker RS.
Mastery of Surgery, Vol. 1, p. 522. Boston: Little, Brown & Co.; 1984.
Schreiber HW. Vagotomie. In Baumgartl F, Kremer K, Schreiber HW. Spezielle
Chirurgie für die Praxis, Vol. II/2, p. 77. Stuttgart: Thieme; 1969.
Siewert JR, Müller C. Operative Therapie des unkomplizierten Ulcus
duodeni. In Allgöwer M, Harder F, Hollender LF, Peiper HJ, Siewert JR.
Chirurgische Gastroenterologie, Vol. 1, p. 460. Berlin: Springer; 1981.
Smith GK, Farris JM. Some observations upon selective gastric vagotomy.
Arch. Surg. 1963; 86:716.
Steele RJ, Munro A. Successful treatment of gastric stasis following proximal
vagotomy. Endoscopy 1989; 21:120.
Taylor TV. Lesser curve superficial seromyotomy. An operation for chronic
duodenal ulcer. Brit. J. Surg. 1979; 66:733.
Taylor TV, Gunn AA. MacLeod DAD et al. Morbidity and mortality after ante-
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duodenal ulcer. Brit. J. Surg. 1985; 72:950.
Taylor TV, Lythgoe JP, McFarland JB, Gilmore IT et al. Anterior lesser curve
seromyotomy and posterior truncal vagotomy versus truncal vagotomy
and pyloroplasty in the treatment of chronic duodenal ulcer. Brit. J. Surg.
1990; 77:1007.
Taylor TV, MacLeod DAD, Gunn AA, MacLennan I. Anterior lesser curve sero-
myotomy and posterior truncal vagotomy in the treatment of chronic
duodenal ulcer. Lancet 1982; II.
Triboulet JP. Progrès dans le traitement de l’ulcère duodénal: la séromyo-
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ed., p. 861. Boston: Little, Brown & Co.; 1986.
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ed., p. 15. Paris: Masson; 1989.
ed., p. 20. Paris:
213
214
Instrument table
Monitor
2
nd
assistant
Aspirator/
irrigator set
OR nurse
Insufflator
1
st
assistant
Electrocautery unit
Surgeon
8.4 Posterior Truncal Vago tom y and Anterior Gastric Seromyotom y (Taylor 1985)
A. Pier , F . Götz
Objectives and Methods
This procedure involves a posterior truncal vagotomy and an
anterior proximal vagotomy by seromyotomy of the anterior
wall of the stomach (see selective proximal vagotomy, chapter
8.3).
Anesthesia
General anesthesia.
Positioning
(Fig. 8.4.1).
Position of the Operating Team
(Fig. 8.4.2).
The surgeon stands between the patient’s legs. The first as-
sistant stands to the right of the patient, and the second as-
sistant and OR nurse to the left. We recommend a reverse Trendelenburg position with the patient’s right side elevated at 45°.
The monitor with the video recorder and light source is located
at the patient’s right shoulder. The respirator and the anesthesiologist are off to the left.
Fig. 8.4.1 Posterior truncal vagotomy and anterior gastric seromyotomy. Positioning.
Position the patient supine in a reverse Trendelenburg position with the
right side elevated, one arm extended, and the legs abducted.
Fig. 8.4.2 Posterior truncal vagotomy
and anterior gastric seromyotomy.
Position of the operating team and
equipment.
Complications
215
The electrocautery unit is positioned on the right side of the
patient. A second monitor for the first assistant if available and
the aspirator/irrigator set are on the left. Place the insufflator in
the first assistant’s line of vision. For the techniques described
in the following paragraphs, a 30-degree laparoscope is essential for better visualization of the surgical site.
Trocar Placement
T4
T5
T1
Fig. 8.4.3 Posterior truncal vagotomy and anterior gastric seromy-
otomy. Trocar placement.
A totalof five ports arerequired. Insert a 10.5-mm laparoscope/cameratrocar (T1) with a trumpet valve into the abdominal cavity about two finger
breadths superior to the umbilicus after establishing the pneumoperi-
toneum. Then insert four instrument trocars under laparoscopic visualization. Ports T3 and T5 contain 10.5-mm instrument trocars to accommodate various dissectioninstruments. Anadditional 5.5-mm instrumenttrocar at port T4 is inserted to permit introducinga retractorto lift theleft he-
patic lobe. We recommend splinting the esophagus with an esophageal
tube or bougie and transillumination of the stomach with a gastroscope.
Open trocar placement is an alternative.
T3
T2
(Fig. 8.4.3).
Complications
Intraoperative Complications
− Perforation of the esophagus.
− Perforation of the stomach.
Corrective action: Close with interrupted sutures running
through all organ layers. Clamp the distal stomach and verify
the closure with a dilute methylene blue solution injected
through a nasogastric tube (see also Fig. 8.3.15).
Postoperative Complications
Thermal damage to the stomach wall with delayed necrosis,
perforation, and peritonitis.
Pseudo-obstructions (Ogilvie’s syndrome) can occur in about 4%
of all patients.
Corrective action: Where symptoms persist for five days or
longer, endoscopy is indicated with dilatation of the pyloric ring
if necessary.
Undetected thermal necrosis of the lesser curvature can lead to
peritonitis.
Step-by-Step Procedure
I Technical preparations
1. Adjust the electrocautery unit to a medium setting.
2. Connect the aspirator/irrigator set
3. Prepare a gastroscope.
4. Start the recording unit.
II Establishing the pneumoperitoneum
1. Select pressure plateau according to patient’s size, age, and
weight (6−8 mm Hg for children; 10−14 mm Hg for adults).
2. Connect all equipment required for operation.
3. Make a skin incision about two finger breadths superior to the
umbilicus for the Veress needle and laparoscope/camera trocar.
4. Insert the Veress needle.
5. Perform safety tests: injection, aspiration, “slurp,” manometer,
and rotation tests.
6. Perform insufflation procedure.
Caution: Insufflate children at 11/min maximum.
III Laparoscopy
1. Place nasogastric tube or orogastric bougie.
2. Insert laparoscope/camera trocar with tapered blunt-tip stylet
about two finger breadths superior to the umbilicus directly
through the linea alba.
3. Insert the instrument trocars under laparoscopic visualization.
4. Explore the peritoneal cavity with the 30-degree laparoscope.
5. In female patients, explore the reproductive organs with a
probe to lift and displace organs, for better visualization.
6. Lift and incise the gastrophrenic ligament at the cardia. Expose
the posterior vagus nerve and excise a 1−1.5-cm segment.
7. Perform a seromyotomy with monopolar electrocautery along
and 2−3 cm inside the lesser curvature.
8. Close the seromyotomy with a continuous suture.
9. Remove the instrument trocars under laparoscopic vision.
Caution: Residual bleeding from the trocar incisions may occur.
216
8.4 Posterior Truncal Vagotomy and Anterior Gastric Seromyotomy (Taylor 1985)
Operative Technique
Fig. 8.4.4 Posterior truncal vagotomy and anterior gastric seromyo- 컄
tomy.
Schematic overview of surgical objectives in seromyotomy with posterior
truncal vagotomy (Taylor’s operation). A seromyotomy is performed
along the lesser curvature from the cardia notch to the crow’s foot to
denervate this portion of the stomach. The operation leaves the antral
branches, the pyloric branch, and the hepatic branches of the vagus nerve
intact whereas the seromyotomy transects the proximal fundic nerves
(see also Fig. 7.1.4).
1 Posterior vagal trunk (transected nerve trunk is circled)
2 Anterior vagal trunk
3 Fundic branches
4 Hepatic branches
5 Anterior antral branches
6 Pyloric branches
The serosa, subserosa, and muscular coat are divided from the anterior cardia notch to the crow’s foot.
T4
2
3
1
4
6
5
T4
T5
T2
Fig. 8.4.5 Posterior truncal vagotomy and anterior gastric seromy-
otomy. Posterior truncal vagotomy.
The initial steps in the procedure are similar to any truncal vagotomy. Lift
the gastrophrenic ligament with a grasper and incise it at the level of the
esophagus. Elevate the left hepatic lobe with a retractor inserted through
port T5 to obtain optimum exposure of the surgical site. After exposing
the right and left margins of the esophageal hiatus, rotate the esophagus
with a swab and dissect above the abdominal aorta to expose the posterior vagal trunk. After identifying the nerve, expose it completely, divide it
with bipolar electrocautery, and resect about 1 cm of the nerve (see
Fig. 8.4.3 for key to instrument numbers).
T3
T3
T2
Fig. 8.4.6 Posterior truncal vagotomy and anterior gastric seromyotomy. Seromyotomy.
Next perform a seromyotomy, transecting the nerve strands along the
lesser curvature. Begin at the cardia, coursing distally to about 1 cm proximal to the crow’s foot. Perform the seromyotomy using monopolar electrocautery. Caution: Do not injure the gastric mucosa (see Fig. 8.4.3 for
key to instrument numbers).
Trocar Placement
컅 Fig. 8.4.7 Posterior truncal vagotomy and anterior gastric seromy-
otomy. Closing the seromyotomy.
Now close the seromyotomy with a seromuscular running suture beginning at the cardia with an initial pre-tied knot and ending with a laparoscopic surgeon’s knot. Use an atraumatic grasper to hold the edges of the
wound when driving the needle. Use absorbable suture material (3 × 0,
metric 2) and a curved needle. The suture should be 15 cm long, secured
with a pre-tied initial knot (see Fig. 8.4.3 for key to instrument numbers).
T3
217
Bibliography
T2
See chapter 8.1.
8.5 Anterior and Posterior T runcal Vagotomy and Pyloroplasty
A. Pier , F . Götz
Goals and Methods
Anterior and posterior truncal vagotomy is the simplest method
of achieving gastric denervation. It may be performed laparoscopically, or thoracoscopically for patients who have undergone
a previous gastric operation. Since the antrum is denervated
with truncal vagotomy, a pyloroplasty is indicated.
Abdominal Truncal Vagotomy
with the patient placed into a moderate left lateral decubitus
position. The monitors with the video recorder and light source
are located to the patient’s right side. The respirator and the anesthesiologist are off to the left.
Electrocautery unit is positioned on the right side of the patient.
The aspirator/irrigator set and a second monitor for the first assistant if available are on the left. The insufflator is placed in the
first assistant’s visual field. For the techniques described below,
a 30-degree laparoscope is essential for better visualization of
the surgical site.
Anesthesia
General anesthesia.
Patient Positioning
(Fig. 8.5.1).
Position of the Operating Team
(Fig. 8.5.2).
The surgeon stands between the patient’s legs. The first as-
sistant stands to the right, and the second assistant to the left of
the patient. We recommend a reverse Trendelenburg position
Trocar Placement
(Fig. 8.5.3).
Intraoperative Complications
Perforation of the Esophagus
The most serious complication is a perforation of the
esophagus. If a perforation is suspected, clamping of the GE
junction and injecting a dilute methylene blue solution into the
esophagus through a nasogastric or oropharyngeal tube will
allow identification of the leak.
Corrective action: Repair the defect with closely placed interrupted sutures, cover it with a gastric fundoplication (Fig.
8.3.15), and test the repair for patency. Manage the defect via a
laparotomy if necessary.