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228
Fig. 8.7.1 Gastrojejunostomy.
Positioning of the surgical team.
8.7 Gastrojejunostomy
Monitor
Surgeon
Operative Technique
OP nurse
Instrument
table
Assistant
Assistant holding
the laparoscope
Equipment
Complications
Antecolic Isoperistaltic Side-to-Side Gastrojejunostomy
After inserting the laparoscope/camera trocar and performing
exploratory laparoscopy, the surgeon places through trocar T5,
a grasper with a swab to assess the mobility of the greater
omentum and the stomach. The surgeon should verify that the
tissues to be anastomosed are free of tumor.
Intraoperative Complications
− The typical complications associated with the pneumoperitoneum and placement of trocars.
− The risk of intraluminal bleeding from the posterior row of
staples in the gastrojejunal anastomosis is particularly high
if the surgeon fails to hold the stapler in an antimesenteric
position on the jejunum or fails to maintain sufficient distance to the vascular structures of the gastrocolic ligament
on the anterior wall of the stomach.
Corrective action: Control bleeding immediately.
Complications
229
T3
T4
T2
T5
T1
Fig. 8.7.2 Trocar placement.
Positioning of the laparoscope/camera and instrument trocars.
Note: The most difficult step in the procedure is the transverse closure of the stapler insertion incision. Make sure to
incorporate the posterior lip of this opening into the transverse closure. It is at times necessary to place retaining sutures to ensure that the Endo-TA instrument closing the defect securely holds this rim, which tends to recede posteriorly.
Postoperative Complications
If the anastomosis has been securely established, there are few
complications specific to this procedure. The anastomosis is
usually functional at an early stage; in the presence of a
complete pyloric stenosis, the increased stomach pressure will
force the stomach to empty through the anastomosis.
Special postoperative care is not necessary. Radiographic ex-
amination of the anastomosis to verify patency may be performed early (postoperative day 3 to 5). Intake of food, espe-
cially liquids, is possible one day after operation. Postoperative
paralytic ileus persists for a relatively short period of time following laparoscopic surgery.
In the presence of radiological and clinical evidence that the
stomach is not emptying properly through the anastomosis, we
recommend careful early gastroscopy. Air insufflation and careful mechanical dilation can restore passage.
If the gastrojejunostomy is done for a benign condition and by
necessity in an antecolic, anterior position because of the limi-
tations imposed by the laparoscopic technique, a vicious cycle
with unrelenting vomiting may occur since the pyloric obstruc-
Fig. 8.7.3 Gastrojejunostomy. Position of the anastomosis.
Antecolic isoperistaltic side-to-side gastrojejunostomy. The most proximally mobile jejunal loop is exposed and lifted over the transverse colon
(arrow). The dashed line shows the position of the anastomosis on the inferior margin of the greater curvature, maintaining a sufficient distance to
the inoperable malignancy causing the obstruction.
tion heals and becomes patent again. In such cases, gastric contents leave the stomach through the reopened pylorus and reenter the stomach through the gastrojejunostomy, filling it to
capacity and overflow through the only opening: the G-E junction. For benign conditions, it is best to remember that with
patients standing or lying on their back the most efficient
drainage is in a straight line, through a retrocolic, posterior
gastrojejunostomy performed by laparotomy. Even then a vicious cycle can occur as the pylorus reopens—which ranks
gastrojejunostomy as an exceptional operation, to be done only
after due consideration of alternative procedures for benign obstructions of the gastric outflow tract.
Step-by-Step Procedure
1. Establish the pneumoperitoneum through the inferior umbilical fossa and insert the laparoscope/camera trocar.
2. Perform exploratory laparoscopy to assess the feasibility of the
procedure.
3. Place the four instrument trocars.
4. Expose the first jejunal loop and oppose it to the anterior inferior greater curvature of the stomach in an antecolic
isoperistaltic manner. Place retaining sutures at both ends.
5. Incise the stomach and jejunum to permit inserting an Endo-TA
stapler (60 mm).
6. Position and fire the 60-mm linear stapler.
7. Close the resulting single-lumen insertion opening with a running suture or by placing laparoscopic TA staples transversely.
8. Examine for patency by air insufflation.
230
8.7 Gastrojejunostomy
T3
1
a
2
3
T5
b
Fig. 8.7.4 a-c Gastrojejunostomy.
a Opposing and attaching the jejunal loop to the distal greater curvature
of the stomach.
After retracting the greater omentum, identify the first jejunal loop and
oppose it to the inferior aspect of the greater curvature of the stomach in
an antecolic and isoperistaltic manner. Avoid placing tension on the jejunal loop. Place long stay sutures through trocars 3 and 5 to join both organs in this position. Maintain a safe distance to the tumor margin distal
to the proposed anastomosis.
b Incising the jejunum and stomach.
Using electrocautery scissors inserted through trocar 2, make a small inci-
sion in the antimesenteric jejunal loop vortex and the stomach slightly
distal to the right stay suture. Extend this incision. In the presence of a pyloric stenosis, the stomach wall can be significantly hypertrophic.
c Creating the anastomosis.
Advance the laparoscopic linear GIA stapler through trocar 2 and insert
one arm into the stomach and the other into the lumen of the jejunum.
Verify that this instrument arm is in a precisely antimesenteric position.
Close the stapler, activate its stapling-cutting mechanism, and remove
the stapler. This produces a relatively large single-lumen opening. Inspect
the rows of staples through this opening to verify the absence of bleeding. Control any bleeding with laparoscopic sutures.
Caution: Do not attempt to control bleeding by electrocautery; the staples
will conduct heat and can produce thermal necrosis.
1 Downstream jejunum
2 Upstream jejunum
3 Greater omentum
T2
c
Complications
231
a
Fig. 8.7.5a, b Gastrojejunostomy. Completing the anastomosis. The
anastomosis is closed either with a running suture (a) or by placing staples
(b). Place the suture or staples transversely to the longitudinal axis of the
intestine to avoid stenosis when closing the jejunum. When closing the
defect with a running suture or staples, make sure that the rows of staples
in the anastomosis do not lie on top of each other but are staggered be-
b
cause intersection points of different anastomotic lines are particularly
susceptible to circulatory disruption. In our experience, no functional impairment will result if a side-to-side jejunojejunostomy is not used. While
this is possible using a similar stapling technique, it doubles the time required for the procedure. We test the patency of the anastomosis by air
insufflation or, better, with a dilute methylene blue solution.
Fig. 8.7.6a Gastrojejunostomy.
The completed anastomosis. The arrows show the direction of isoperistal-
tic flow through the jejunal loop.
Fig. 8.7.6b As an additional step, the surgeon may elect to create a sideto-side jejunal anastomosis about one hand width below the transverse
colon. The arrows indicate the direction of flow as in Fig. 8.7.6a.
232
8.8 Current Status of Laparoscopic Management of Duodenal Ulcers
N. Katkhouda
Owing to multiple epidemiologic factors, general hospital admissions for patients with duodenal ulcers have significantly
decreased from their high in the 1950s. There has also been a
decline in the number of elective operations, both open and laparoscopic, performed for duodenal ulcers (DU). The number of
patients being admitted for emergency operations, such as for
the treatment of a perforated ulcer or gastric outlet obstruction,
remains stable.
Management of Acute Non-Complicated
Duodenal Ulcer
Nonoperative ulcer therapy has undergone a major revolution
since 1992, when treatment for the eradication of Helicobactor
pylorii was introduced. Following the National Institutes of
Health (NIH) Consensus Conference guidelines in 1994, all peptic DU should be tested for the presence of Helicobacter pylori
(HP) and the bacteria should be eradicated using a triple therapy regimen only if the tests are positive for HP. In this situation,
data from Tyttgat and others show that recurrence after
successful eradication is less than 10% at 1 year. Management of
peptic ulcer disease with H2 blockers is ineffective leading to a
90−100% recurrence rate within 1 year on stopping maintenance therapy. Recent data published by Laine show that low
recurrence rates after successful eradication of HP have been
overestimated. It is actually 20% at 6 months.
Patients on non-steroidal anti-inflammatory drugs (NSAIDs)
especially elderly women over 60 years old experience a high
incidence of gastroduodenal ulcers and do not benefit from protection with H2 blockers. Those drugs actually hide symptoms
were placed on prophylactic H2 blockers than in patients not on
H2 blockers. This group of patients might benef it from elective
surgical treatment especially if the ulcer was complicated.
Moreover, 6% of the patients are Helicobacter negative and may
be candidates for elective surgical treatment.
It is debatable whether a definitive antiulcer operation should
be performed at the same time as the emergency procedure.
Published data seem to indicate that a post-operative eradication of Helicobacter pylori is warranted to prevent recurrent
ulceration (Sebastian). Gastric outlet obstruction due to chronic
duodenal ulcer can be treated with laparoscopic vagotomy and
antrectomy. Our experience with this procedure in 16 patients
has shown good results, with no mortality and a very low morbidity.
Personal Data
Laparoscopic Gastrectomy
Sixteen gastrectomies were performed between 1992 and 1996.
The indication was gastric outlet obstruction due to chronic
duodenal ulcers. The technique consisted of truncal vagotomy
and antrectomy with a Billroth II reconstruction, as performed
in open surgery. The assisted technique is our method of choice
and reduces OR time by
only 2 complications: one hematoma, which was drained, and
one paralytic ileus.
1
/2 hours. There were no deaths and
Laparoscopic Vagotomy
Ninety-six laparoscopic posterior truncal vagotomies and anterior seromyotomies were performed. The follow-up interval is
5 years. The mean OR time was 50 minutes. There was no mortality. The morbidity was 8% and the recurrence rate was 3.4% at
5 years.
We performed 10 highly selective vagotomies using the Harmonic Shears (Ethicon Endosurgery). The procedure lasted 1
hour and all patients left the hospital within 23 hours. There
were no complications and all ulcus healed at 2 months.
Summary
Study Results
Recent studies published independently by Jordan and Hoffman
with a greater than 25-year follow-up showed a low recurrence
rate for ulcers after highly selective vagotomy, with a 15% recurrence rate in the first study and a slightly higher rate in the second study. Highly selective vagotomy is therefore an effective
and safe operation for the treatment of an intractable chronic
duodenal ulcer. This operation can now be performed safely laparoscopically using new tools such as the harmonic scalpel
(LCS, Ethicon Endosurgery Inc, Cincinnati, OH).
Management of Complicated Duodenal
Ulcer
Laparoscopic surgery plays a role in the treatment of complications of ulcer disease such as perforation with peritonitis. The
results of laparoscopic treatment in several published studies
and in our personal study of 20 patients were excellent.
In summary, when indicated, laparoscopic operation will probably replace open operation for the management of an intractable chronic duodenal ulcer. Laparoscopic highly selective
vagotomy is the operation of choice for intractable uncomplicated duodenal ulcers. The management of complicated ulcers
should be performed laparoscopically if expertise is available.
Bibliography
Goh P, Kum C. Laparoscopic Billroth II gastrectomy: A review. Surg. Oncol.
1993; 1 (suppl. 2):13−18.
Katkhouda N, Mouiel J. A new technique of surgical treatment of chronic
duodenal ulcer without laparotomy by videocoelioscopy. Am. J. Surg.
1991; 161:361−369.
Katkhouda N, Mouiel J. Treatment of complications of peptic ulcers. In Arre-
gui ME et al. (eds.). Principles of Laparoscopic Surgery, pp. 260−267. New
York: Springer-Verlag; 1995.
Walsh JH, Peterson WL. Drug Therapy: The treatment of helicobacter Pylori
infection in the management of peptic ulcer disease. N. Engl. J. Med. 1995;
333:984−991.
8.9 Thoracoscopic Truncal Vagot om y
F. Köc kerling
233
Goals and Methods
An anastomotic ulcer following a Billroth I or II gastric resection
or a Whipple procedure is a serious complication. The incidence
is 1−5%, occurring five to ten times more frequently in men.
The consensus is that this recurrent ulcer is the result of excessive acid production in the remaining part of the stomach. Three
factors are important:
1. Excessive size of the residual stomach with insufficient re-
duction of the parietal cells following gastric resection.
2. Residual antrum left by error in the stump of the duodenum
produces clinical symptoms resembling a Zollinger-Ellison
syndrome as a result of increased gastric hormone production in the absence of acid inhibition.
3. Hypersecretion of acid due to a gastrin-producing tumor
(Zollinger-Ellison syndrome).
If hypergastrinemia due to a residual antrum or a Zollinger-Ellison syndrome can be excluded, treatment with medication is
usually attempted first.
Nonoperative treatment of an anastomotic ulcer following gas-
tric resection is frequently ineffective and is plagued by a high
rate of failure (Chisholm et al. 1992). Following a gastric opera-
tion. Heliobacter pylorii is detected significantly less frequently
in the presence of high reflux scores and bile-acid mixtures
(O’Connor et al. 1986). According to the “leaking roof” theory, it
is not Heliobacter pylorii that damages the protective layer of
mucus in an anastomotic ulcer, but bile reflux (O’Connor 1986,
Goodwin 1988). This leaves the mucus membrane unprotected
against the action of the acid. The result is that the anastomotic
ulcer frequently requires permanent treatment with H2-recep-
tor blockers or proton pump inhibitors. If the patient is not compliant or there is repeated recurrence, surgical intervention is
indicated.
Repeat surgical intervention in the abdomen, such as gastric resection or abdominal vagotomy, can be difficult and compli-
cated (Schirmer 1982). An effective alternate procedure is a
truncal vagotomy performed through a left lateral thoracotomy
(Lehr 1982). The transthoracic approach offers the advantage of
access to a new operative site through an undisturbed anatomi-
cal area. This makes a complete vagotomy a comparatively easier and safer operation.
Increasing experience with thoracoscopic surgery has made it
possible to perform transthoracic truncal vagotomy as a minimally invasive procedure.
Contraindications
Thoracoscopic truncal vagotomy should not be performed in
the presence of cardiac, pulmonary, or other systemic risk factors, as well as in contraindications to general anesthesia including placement of separate airways for each bronchus, which
involves collapsing the left lung. Risk factors that preclude a left
thoracotomy to treat possible complications are also contraindications, as is a previous left thoracotomy with pleural adhesions.
Surgical Risks and Patient Information
The patient should be informed of the surgeon’s level of experience with thoracoscopic operations. Any possible complications of thoracoscopic procedures in general and the thoracoscopic truncal vagotomy in particular must be discussed with
the patient. These include the risk of perforations of the
esophagus, aorta, pericardium, thoracic duct, and the
parenchyma of the lung, as well as the standard risks of a
thoracoscopic procedure such as bleeding from intracostal vessels or subcutaneous emphysema. The surgeon should also discuss the possibility of conversion to a posterolateral thoracotomy with the patient in detail. The possible occurrence of injuries due to positioning should also be mentioned.
Special Preparations
The operation is performed under general anesthesia with
placement of a double-lumen bronchial airway and separate
ventilation of each lung. To provide sufficient exposure for a
left-side thoracoscopy and exploration of the distal esophagus,
the lef t lung must be collapsed. The esophagus is temporarily
splinted with a large nasogastric tube to facilitate subsequent
dissection.
Anesthesia
General anesthesia with placement of a double-lumen
bronchial airway and planned collapse of the left lung.
Indications
A thoracoscopic truncal vagotomy is indicated for treatment of a
jejunal peptic ulcer following a Billroth I or II gastric resection
or a Whipple procedure after nonoperative therapy of the ulcer
has failed. Hypergastrinemia and Zollinger-Ellison syndrome
must be excluded first.
Patient Positioning and Position of the
Operating Team
(Fig. 8.9.1).
Trocar Placement
(Fig. 8.9.2).
234
8.9 Thoracoscopic Truncal Vagotomy
Fig. 8.9.1 Thoracoscopic truncal vagotomy. Patient
positioning and placement of the operating team.
As for a left posterolateral thoracotomy, the patient is
placed in the right lateral decubitus position with the
left side up. The surgeon stands in back of the patient.
The monitor is placed in front of the patient so that the
surgeon can look past the operative site to the monitor.
The assistant holding the thoracoscope/camera also
stands in back of the patient, above the surgeon, and
guides the camera beneath the surgeon’s right arm. A
second assistant stands in front of the patient and faces
a second monitor placed between surgeon and camera
assistant. The OR nurse and instrument table are at the
foot of the operating table. Other equipment may be
positioned as desired.
Assistant holding
the thoracoscopic
Assistant
Surgeon
10 mm
10 mm
Optik (12 mm)
optional (5 mm)
Monitor
Instrument table
컅 Fig. 8.9.2 Thoracoscopic truncal vagotomy. Trocar placement.
T1 10/12-mm thoracoscope/camera trocar inserted in the seventh or
eighth intercostal space, along the posterior axillary line.
T2-T3 10/12-mm instrument trocars inserted along the anterior axillary line,
as far apart as possible (such as at the sixth and tenth intercostal
spaces). These trocars form a semicircle with the thoracoscopic/
camera trocar, around the lateral aspect of the distal esophagus.
T4 If the two instrument or working trocars are not sufficient, a fourth 5-
mm instrument trocar can be placed in the tenth or eleventh intercostal space along the posterior axillary line.
Bibliography
235
Complications
Intraoperative Complications
− Injuries to the parenchyma of the lung when placing the trocars.
− Perforation of the esophagus.
− Injuries to the thoracic aorta.
− Injuries to the pericardium.
− Failure to collapse the left lung.
− Bleeding from vessels in the paraesophageal connective
tissue.
− Injury to the thoracic duct.
− Development of subcutaneous emphysema in the presence
of a pulmonary parenchymal fistula.
− Migration of the tube after placement of the bronchial airway.
− Insufficient gas exchange with left lung collapsed.
Corrective action: If one of these complications limits the safe
execution of the planned operation, conversion to thoracotomy
is indicated. Some of the complications can be managed if the
surgeon is sufficiently proficient in thoracoscopic suturing techniques. The experienced surgeon may be able also to reposition
the double-lumen endotracheal tube under bronchoscopic con-
trol.
Postoperative Complications
− Postoperative bleeding.
− Wound infection.
− Pleural effusion.
− Esophageal perforation not detected intraoperatively.
− Tension pneumothorax due to insufficient drainage of a
parenchymal leak.
− Chylothorax.
Corrective action: Depending on the findings, treatment may include repositioning drains, thoracoscopic intervention, or for
severe complications, thoracotomy.
Step-by-Step Procedure
1. Insert the working trocars under thoracoscopic visualization.
2. Explore the chest and identify the distal esophagus.
3. Transect the pulmonary ligament and retract the collapsed
lung superiorly.
4. Incise the mediastinal pleura and circumferentially expose the
distal esophagus.
5. Separate and transect the individual nerve plexuses and the
paraesophageal connective tissue from the esophagus.
6. Expose and transect the posterior vagal trunk.
7. Expose and transect the anterior vagal trunk. Send a one-centimeter segment of each nerve for histologic examination.
8. Continue the circumferential exposure of the distal esophagus
for 3−5 cm.
9. Place a chest tube through one of the trocar ports.
Operative Technique
Diaphragm Pulmonary ligament Pericardium
Lung
Fig. 8.9.3 Thoracoscopic truncal vagotomy. Exposure of the distal
esophagus and transection of the pulmonary ligament.
First, carefully expose the distal esophagus superior to its passage into the
esophageal hiatus. To do this, the lung must be collapsed. If this is not the
case, the air can be pressed out of the parenchyma of the lung with a
compress mounted on a grasper and a fan retractor, after which the lung
is retracted superiorly. This generally requires dividing the pulmonary ligament, which can be done with electrocautery (hooked electrode or scissors).
Bibliography
Chisholm EM, et al.: Thoracoscopic vagotomy: a new use for the laparoscope.
Br. J. Surg. 1992;79:254
Goodwin CS: Duodenal ulcer, campylobacter pylori, and the “leaking roof”
concept. Lancet 1988;24/31:1467
Lehr L, Pichlmayr R: Low-risk thoracic vagotomy for anastomotic ulceration.
World J. Surg. 1982;6:93
O’Connor HJ, et al.: Effect of duodenal ulcer surgery and enterogastric reflux
on campylobacter pyloridis. Lancet 1986;22:1178
236
8.9 Thoracoscopic Truncal Vagotomy
Fig. 8.9.4 Thoracoscopic truncal vagotomy. Incision of the mediastinal
pleura and circumferential exposure of the distal esophagus.
The mediastinal pleura is incised over the distal esophagus with a hookedelectrode electrocautery, after which the distal esophagus is exposed by
blunt dissection with a swab. The circumferential exposure of the
esophagus must extend over 5 cm of its distal length.
Fig. 8.9.5 Thoracoscopic truncal vagotomy. Separation and transection
of individual nerve plexuses and the paraesophageal connective tissue.
During the circumferential dissection to expose the esophagus all identifiable minor nerve fibers and connective tissue strands are lifted and
divided with hooked-electrode electrocautery and/or curved laparoscopic
scissors.
Fig. 8.9.6 Thoracoscopic truncal vagotomy. Exposure and transection of
the posterior vagal trunk.
Using a swab, the distally mobilized esophagus is lifted and turned to expose the anterior and posterior trunks of the vagus nerve. First the posterior vagal trunk is carefully exposed. It is clipped proximally and distally,
and then a 1-cm section is resected and sent for frozen section.
Fig. 8.9.7 Thoracoscopic truncal vagotomy. Transection of the anterior
vagal trunk.
Next the anterior vagal trunk is identified, grasped, and lifted with laparoscopic scissors. Then the nerve is clipped proximally and distally, and a 1cm section is resected and sent for frozen section. Next, ensure that the
circumferential clearing of the esophagus extends 3−5 cm to avoid
missing any branching nerve fibers.
After hemostasis is obtained, a chest tube is placed through one of the
trocar ports, and the other incisions are closed in layers.
8.10 Comments on Thorascopic T runcal Vagotomy
F. Dubois
237
Thoracoscopic vagotomy is a very useful, easy and safe procedure, as described by F. Köckerling in the preceding chapter.
As early as 1943, Dragstedt (1947) performed bilateral truncal
vagotomy for peptic ulcer through a left thoracotomy. However
the credit to do vagotomy by thoracoscopy goes to Wittmoser
(1992) in the early 1950’s. The operation was then done in two
stages at a three weeks interval well below the arch of the aorta
and was combined with a splanchnicectomy to avoid gastric
stasis.
To simplify this technique, we have developed the resection of
both vagal trunks in one stage through a unilateral approach,
usually the left side (Dubois 1991). Our technique is very similar
to the one described except for some details. A double lumen
tracheobronchial intubation is useful but not absolutely neces-
sary. In many patients total collapse of the lung can be avoided
and the risk of postoperative pulmonary complications reduced.
Using the “open” procedure, we place a 10-mm trocar in the
posterior axillary line of the 6
thoracoscope. After visual exploration, two 5-mm trocars are
introduced into the mid-axillary line and optimally separated in
the intercostal spaces, to avoid “dueling” of the operating instruments. If necessary, a fourth trocar of 5-mm can be inserted
into the anterior axillary line for placement of a lung retractor.
To avoid the theoretical risk of air embolism, a CO
pneumothorax is established at a low pressure. This also helps
to diminish capillary oozing.
Usually it is not necessary to transect the pulmonary ligament.
The mediastinal pleura is opened over the aorta from a high
level of 4−5 cm down to the hiatus. The esophagus is liberated
gradually and all nerve trunks and twigs are severed as indi-
cated by Köckerling. The risk of bleeding is low at this level since
the periesophageal area is avascular. In case the right pleura is
injured, insufflation will keep the lung expanded until the
esophagus is returned to its original position to cover the
pleural rent. If there is no bleeding nor air leak, there is no ne-
cessity for drainage after lung expansion; otherwise a chest
tube for drainage is placed.
Postoperatively a naso-gastric tube is left in place for 24 hours to
prevent a possible acute gastric dilatation. The usual hospital
stay is three days. At present, the indication for vagotomy, espe-
cially of both trunks is only rarely present. The thoracoscopic
approach is favored for a recurrent duodenal ulcer after a pre-
vious abdominal operation and also for an anastomotic ulcer.
Chronic duodenal ulcers that are resistant to nonoperative
treatment are also good indications. From 1991 to 1994, twenty
four patients were operated, all except one through a left approach. Two post-operative complications occurred:
th
intercostal space for the
In all patients the ulcers healed. There has been a late recurrence in one patient with alcoholic pancreatitis. The risk of
post-vagotomy gastric stasis was reported at 40% by Dragstedt.
It seems nearer to 10%. It is not linked to pyloric spasm since intraluminal endoscopy shows the pylorus to be wide open. In reality, there seems to exist an achalasia with static contraction of
the antrum and absent peristalsis, resulting in rapid evacuation
of liquids but stasis of solid food. A semi-liquid diet is therefore
recommended during the first weeks together with drugs increasing the antral motility. In case of real pyloric spasm or if
the troubles of gastric emptying persist too long a time, a pyloric
dilatation by endoscopic balloon might be performed. This has
been done twice in our 24 patients.
We observed no post-vagotomy diarrhea. Our patients were
carefully selected to avoid performing truncal vagotomy in
patients with chronic diarrhea.
Bibliography
Dragstedt LR. Section of the vagus nerves to the stomach in the treatment of
peptic ulcer. Ann. Surg. 1947; 126:687−708.
Dubois F. Laparoscopic Vagotomies in Problems in General Surgery, vol. 1,
p. 348−357. Philadelphia: Lippincott; 1991/8.
2
Jian R. Troubles de la vidange gastrique. Presse Med. 1992; 21:1072−1078.
Wittmoser R. Thoracoscopic sympathectomy and vagotomy.In Cushieri et al.
Operative manual of endoscopic surgery, vol. 1, p. 110−133. Berlin:
Springer-Verlag; 1992.
− temporary left phrenic nerve palsy after a long and difficult
pleurolysis for major pleural adhesions,
− transient dysphagia for three weeks probably linked to an intramural esophageal hematoma.