The patient is positioned on the operating table in the supine position. At least one arm should be tucked in most instances to provide more room for the operating team and any mechanical retractors. Care must be taken to ensure that the patient is properly off-loaded to prevent nerve injury in both the upper and lower extremity and to prevent back pain in the lordotic areas of the lumbar and cervical spine. A footboard should be
used so that the patient will not move during the procedure when reverse Trendelenburg positioning may cause shifting of the patient on the operating table. Patients should be secured to the operating table using a safety strap. The patient should have a large bore intravenous line and, in the high-risk patient, may need central venous pressure monitoring as well as invasive blood pressure monitoring with an arterial line. A urinary catheter is placed for urine output monitoring and a nasogastric tube is placed once the patient has undergone rapid sequence intubation and the endotracheal tube has been secured. The nasogastric tube is helpful for decompression of the stomach as well as for identifying the esophagus at the diaphragmatic hiatus and as a retraction device on the greater curve of the stomach. Patients should be offered perioperative thoracic epidural analgesia which should be placed prior to the induction of general anesthesia. All patients undergoing PGV should be considered to have a full stomach and therefore require rapid sequence intubation techniques. Muscle relaxation is necessary for open PGV. The patient’s abdomen and lower chest is clipped in the operating room and the patient’s skin is prepared with chlorhexidine-alcohol, which has recently been shown to be superior to povidone-iodine in preventing postoperative surgical site infection. Sterile draping should include the lower chest well above the xiphisternum.

An upper midline, epigastric incision is recommended when performing open PGV and provides excellent overall exposure. Infrequently, the incision needs to be carried below the umbilicus. An alternative chevron incision may be used, but the disadvantages of muscle transection seem to outweigh the exposure benefits in most cases. Care must be taken to avoid injuring the periosteum of the xiphoid process in order to prevent the rare but under-reported incidence of heterotopic ossification of the abdominal wound. The xiphoid, in most instances, does not need to be excised. Once the skin has been incised, blunt bilateral force is used to transect the subcutaneous tissue in a bloodless field, and this technique reliably identifies the midline fascia and linea alba in situations when previous laparotomies have not been performed. The midline fascia is incised precisely in the midline to avoid disruption of the confluence of the anterior and posterior rectus sheaths. The properitoneal fat is sharply transected and the peritoneum is opened to the full extent of the wound, avoiding any adhesions when present. The ligamentum teres hepatis does not need to be transected in most cases and may be used to patch a perforated duodenal ulcer when omentum is not readily available. Full abdominal exploration is mandatory in order to assess the suspected pathology as well as identify any other unsuspected pathology, unless mitigating circumstances would call for a truncated exploration, such as dense adhesions, when the risk of enterotomy may outweigh the benefits of exploration. Any peritoneal soiling is quickly addressed with suction, irrigation, and control of ongoing spillage from the perforated viscous. The left triangular ligament may be incised to provide right upward mobilization of the lateral segment of the left lobe of the liver for better exposure of the esophageal hiatus. A laparotomy sponge is placed lateral and posterior to the spleen to release any tension on the gastrosplenic ligament, thus minimizing the risk of splenic injury. A self-retaining retractor is next implemented and attached to the operating table. A Thompson or Bookwalter retractor is preferred over a Balfour retractor in most cases. In order to provide the best exposure and retraction, the liver needs to be retracted superiorly and to the right and the parieties need to be placed on tension inferiorly and mediolaterally. The upper abdominal retractors should be placed with the patient in Trendelenburg position. Once the retractors are in place, reversing the Trendelenburg position will provide optimal exposure of the upper abdomen. All of the many important surgical aspects of PGV and the emergency management of perforation and bleeding will be able to be addressed without any further manipulation of the retractor system. In clinical scenarios of duodenal ulcer hemorrhage, an anterior longitudinal gastroduodenostomy across the pylorus is performed and the bleeding artery is ligated, making sure to control the transverse pancreatic artery with a U stitch. After controlling the arterial hemorrhage
the duodenotomy is closed horizontally in a Heineke–Mikulicz fashion. A perforated duodenal ulcer should be patched with well vascularized omentum when available and should not be closed primarily especially if the closure would create narrowing of the duodenum. Closure and patching is an acceptable modification of Graham’s technique, when the ulcer is small and would not result in significant stricturing. The PGV can be added to both of these procedures when indicated. A chronically scarred and obstructed duodenum should be managed either by resection or by PGV with gastrojejunostomy to alleviate the obstruction and to minimize recurrent duodenal ulcer.

PGV requires a surgeon with a tremendous requisite knowledge of vagal and foregut anatomy and a meticulous technical skill-set for best results. The procedure should be able to be performed in less than 2 hours and consists of four (or five) important steps for optimal denervation (completeness of vagotomy), preservation of antral-pyloric mobility, and prevention of ulcer recurrence. The procedural steps involved in PGV are that of anterior lesser omental dissection, posterior lesser omental dissection, distal esophageal dissection, lesser curvature closure, and possibly consideration of extended PGV in the area along the greater curvature across the incisura described by Rosati in order to bring cure rates as high as 98%. The steps in the operation are not necessarily done sequentially and may be altered depending on local conditions for a given patient.

The PGV is usually begun at the level of the esophageal hiatus and the distal esophagus (Fig. 8.1

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