Step 1: Surgical Anatomy

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  After giving off the hepatic branch, the anterior nerve of Latarjet courses inferiorly, within the anterior leaflet of the gastrohepatic ligament, medial to the lesser curve.

  
  
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  Similarly, after giving off the celiac branch, the posterior nerve of Latarjet courses inferiorly, within the posterior leaflet of the gastrohepatic ligament, medial to the lesser curve.

  
  
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  Both nerves of Latarjet terminate with branches to the antrum and pylorus. Although classically described resembling a crow’s foot configuration, this fan-like configuration of nerves is inconsistent.

  
  
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  Highly selective vagotomy (HSV) or parietal cell vagotomy entails transection of the proximal gastric branches of the anterior and posterior descending nerves of Latarjet, with preservation of the distal branches to the antrum and pylorus. Vagal division should terminate 7 cm proximal to the pylorus, whose location is marked by a prominent vein. ( Figure 11-1 )

  
  

  
  

  
  

  

  
  

Step 2: Preoperative Considerations

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  HSV denervates the proximal three fourths of the stomach and the parietal cell mass. Unlike truncal and selective vagotomy, HSV does not require a concomitant gastric drainage procedure.

  
  
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  By default, the celiac division of the posterior vagus and the hepatic division of the anterior vagus are preserved during HSV so that innervation to the biliary tract, and small and large bowel remains intact.

  
  
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  HSV should be the procedure of choice in patients undergoing elective surgery for refractory duodenal ulcer disease, provided they do not have gastric outlet obstruction.

Step 3: Operative Steps