Step 1: Surgical Anatomy
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Division of the vagus nerves is an important part of any operation whose goal is to control gastric acid secretion. The left vagus nerve that crosses anteriorly at the distal esophagus and the right vagus branch that crosses posteriorly can be interrupted intraabdominally by one of three main operations. A truncal vagotomy consists of the two trunks being divided approximately 5 cm cephalad from the gastroesophageal junction. A selective vagotomy involves division of the vagal branches distal to the celiac (posterior) and hepatic (anterior) branches. This operation is not commonly performed. A highly selective, or parietal cell, vagotomy results in denervation of only the proximal two thirds of the stomach by dividing the anterior and posterior nerves of Latarjet.
Step 2: Preoperative Considerations
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With the improved medical agents to control gastric acid and the increased understanding of the role of H. pylori infection, few patients are candidates for surgical intervention for gastric and duodenal ulcer disease. More often, surgical therapy is relegated to those patients with severe and emergent complications of ulcer disease. The recent advances in video optics and instruments coupled with the growing number of laparoscopic surgeons comfortable with procedures on the foregut, such as fundoplications and Roux-en-Y gastrojejunostomies, have led to the application of minimally invasive techniques for ulcer disease.
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A minimally invasive approach may potentially reduce the immediate postoperative morbidity following surgery for ulcer disease. The indications for laparoscopic therapy for ulcer disease remain the same as for open surgery: failure of medical therapy, and obstruction, perforation, and concern for malignancy. Common minimally invasive antiulcer procedures include truncal vagotomy and antrectomy with either Billroth I or Billroth II reconstruction; vagotomy and pyloroplasty; and parietal cell vagotomy. Several series, largely from Europe, report good results with ulcer recurrence using a posterior truncal vagotomy combined with either an anterior seromyotomy or anterior linear gastrectomy. For patients with gastric outlet obstruction, a laparoscopic truncal vagotomy with pyloroplasty, and vagotomy with antrectomy are both valid surgical options. If a perforation occurs, a laparoscopic omental patch with simple closure, followed by peritoneal lavage, is suitable most of the time. A more definitive antiulcer procedure may be performed if there is minimal contamination and the condition of the patient allows it.
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Laparoscopy requires pneumoperitoneum, so the acutely ill or septic patient may not tolerate increased intraabdominal pressure and would not be a candidate for a laparoscopic approach. Relative contraindications to a laparoscopic approach include an acutely bleeding ulcer and the difficult duodenal stump.
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The preoperative evaluation of the ulcer patient for laparoscopy is similar to that for open gastric procedures. Patients with acute gastroduodenal perforations must be hemodynamically stable to tolerate pneumoperitoneum. Chronically ill patients with ulcer disease should have their nutritional status optimized.
Step 3: Operative Steps
1.
Incision
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Trocar placement mimics that of most laparoscopic foregut procedures. The patient is placed in the lithotomy position with the use of stirrups or, preferably, a split-leg table. ( Figure 17-1 )
Figure 17-1
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All 5-mm trocars are suitable if no specimens are to be retrieved and no staplers are to be used. The curved suture needle can be bent to resemble a ski needle to fit through the 5-mm trocar.
2.
Dissection
Laparoscopic closure of gastroduodenal perforation
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Different techniques have been described for laparoscopic treatment of a perforated peptic ulcer. Following the principle of conventional open repair, ulcer closure may be performed by simple or running suture techniques incorporating omental patches. ( Figure 17-2 )
Figure 17-2
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Laparoscopic guided techniques for creating plugs of omentum of the ligamentum teres hepatis have been described. Sutureless techniques including plugs of gelatin sponges or fibrin glue have been used but are associated with higher leak rates, particularly if the perforation is larger than 5 mm in diameter. A simple suture technique incorporating an omental patch based on Graham’s closure and not using any additional foreign bodies is preferable.
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The peritoneal cavity is then copiously irrigated with several liters of warm normal saline. All four quadrants and especially the pelvic cavity should be rinsed until the effluent is clear. Tilting the patient from side to side and using Trendelenburg and reverse Trendelenburg positions assist with irrigation.
3.
Laparoscopic Highly Selective Vagotomy
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The peritoneal cavity is accessed safely just above the umbilicus, approximately 12 cm from the xiphoid process. An open cut-down technique or optical trocar may be used to gain entry. The additional 5-mm trocars are placed as shown in Figure 17-1 . A liver retractor is brought in through the right upper quadrant trocar and secured with a stationary side-rail mounted arm.
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The planned extent of the vagotomy is marked with sutures. A stitch is placed just to the left of the anterior vagus nerve where it emerges from under the peritoneum at the gastroesophageal junction. A second stitch marks the lower limit of the planned vagotomy, usually at the level of the first branch of the crow’s foot. ( Figure 17-3 )
