Laparoscopic Proximal Gastric Vagotomy

Namir Katkhouda

Joerg Zehetner

Indications/Contraindications

The objective of the procedure is to divide all vagal nerve fibers innervating acid-producing cells of the stomach while preserving the terminal branches of the main vagal trunks and the nerves of Latarjet, thereby maintaining adequate antral motility. The success of the operation depends on meticulous technique because leaving a single fundic nerve branch intact will allow continued acid secretion in the corresponding gastric secretory zone, leading to early recurrence.

In the elective setting the current indications for the surgical treatment of duodenal ulcer disease are as follows:

Patients in whom the disease is resistant to medical treatment despite medical therapy for at least 2 years and/or two or more documented recurrences after thorough medical treatment.
Patients who cannot be followed regularly because of geographic or socioeconomic reasons or who cannot afford medication.
Patients with complications such as perforation or hemorrhage.

Contraindications for the laparoscopic approach are previous operations on the stomach or upper abdomen with major adhesions and portal hypertension, especially in combination with coagulopathy. Other contraindications are patients with untreated Helicobacter pylori infection or patients on nonsteroidal anti-inflammatory drugs before presentation.

Preoperative Planning

The preoperative evaluation of the patient includes evaluation of the general medical status, the operative risk factors, comorbidities, and endoscopic and secretory investigation of the peptic ulcer disease.

The endoscopic examination of the upper gastrointestinal tract is done routinely and allows direct inspection of the diseased area. The duodenal ulcer is typically a linear defect without associated stenosis or hemorrhage. It allows biopsies to rule out possible
H. pylori infection as well as other rare diseases which are associated with duodenal ulcers (Crohn’s disease). Other diseases such as esophageal cancer or gastroesophageal reflux disease can be ruled out, as these are diseases with similar symptoms to ulcer disease.

The secretory tests include measurements of basal acid output and peak acid output after stimulation with pentagastrin. These tests are necessary to evaluate the degree of acid hypersecretion in patients who are intractable to medical treatment. The serum gastrin level should always be assessed to exclude gastrinoma.

A radiographic videoesophagram and upper gastrointestinal study can be added if the endoscopy cannot assess a possible postpyloric stenosis.

Surgery

As with all laparoscopic procedures, this procedure requires general anesthesia and endotracheal intubation. A nasogastric tube is necessary to deflate the stomach before establishing pneumoperitoneum. A urinary catheter is not routinely placed.

Positioning

The patient is positioned in an inverted Y position with the operating surgeon between the legs (French position). The video monitor is positioned above the head and slightly toward the left shoulder of the patient. If the video tower does not provide a flexible screen, the video endoscopic tower is placed on the left of the patient and a second monitor on the right of the patient. The second (camera) assistant stands to the right of the patient and the first assistant and the scrub nurse stand to the left of the patient. The trunk of the patient is elevated 15 degrees in a reverse Trendelenburg position.

Trocar placement

After establishing the pneumoperitoneum with a Veress needle and an optical trocar or with the Hassan technique, first a 12-mm trocar is inserted in the midline approximately one-third of the distance between the umbilicus and the xiphoid process.

A second 12-mm trocar is placed in the left subcostal position in the midclavicular line as a primary working port. Three additional 5-mm or 10-mm trocars are used:

One in the subxyphoid position used to make a subcutaneous tract for the introduction of the Nathanson Hook Liver Retractor (Automated Medical Products Corporation, Sewaren, NJ). This retractor is secured to the right bed post using an Iron Intern (Automated Medical Products Corporation, Sewaren, NJ).
Two retracting ports are placed in the right and left subcostal margins.

Technique

In addition to the standard laparoscopic instruments we recommend the following instruments:

Clip appliers
Two laparoscopic needle holders
An L-shaped hook coagulator
Absorbable monofilament sutures
Endoloops with preformed Roeder knot
Application system for fibrin sealant spray
Ultrasonically activated coagulating shears

There are two major techniques of laparoscopic proximal gastric (highly selective) vagotomy (PGV) for the surgical treatment of chronic duodenal ulcer disease.

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