Step 1: Surgical Anatomy
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Selective vagotomy entails transection of both the descending branch of the anterior vagus nerve (anterior nerve of Latarjet) distal to the hepatic branches, and the descending branch of the posterior vagus (posterior nerve of Latarjet) distal to the celiac branches. ( Figure 10-1 )
Figure 10-1
Step 2: Preoperative Considerations
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Similar to truncal vagotomy, selective vagotomy completely denervates the stomach and requires a concomitant gastric drainage or resective procedure.
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The solitary pyloric branch of the hepatic division of the anterior vagus nerve and the celiac branches of the posterior vagus nerve are undisturbed, preserving the innervation to the biliary tract, small bowel, and proximal large bowel.
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Selective vagotomy is the least performed of all the vagotomy subtypes likely due to the difficulty in identifying the celiac branch of the posterior vagus nerve.
Step 3: Operative Steps
1.
Positioning and Incision
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The patient is positioned supine with both arms extended. A footboard is attached to the bed to support the patient.
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A midline incision allows for sufficient visualization of the upper stomach and esophagus.
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An abdominal wall retractor is placed for cephalad retraction. A sweetheart retractor attachment is placed in the midline to gently retract the junction of the esophagus and diaphragm. The patient is placed in steep reverse Trendelenburg position.
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An orogastric tube is advanced into the proximal stomach and helps serve as a guide for palpation of the esophagus.
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The operating surgeon stands to the patient’s right.
2.
Dissection
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The gastrophrenic ligament is divided and the dissection carried over the anterior portion of the phrenoesophageal ligament towards to the gastrohepatic ligament. ( Figure 10-2 )
