Step 1: Surgical Anatomy
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The anterior or left vagus nerve is a thick, visible structure which lies just right of the midline along the anterior surface of the intraabdominal esophagus. ( Figures 9-1 and 9-2 )
Figure 9-1
Figure 9-2
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The posterior, or right vagus nerve, is thinner and lies to the right of the esophagus, closer to the aorta than the esophagus. ( Figures 9-1 and 9-2 ) Palpation of a thin cord posterior to the esophagus will typically reveal its location.
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Truncal vagotomy requires skeletonization of the anterior and posterior vagus nerve trunks with complete transection.
Step 2: Preoperative Considerations
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When performed properly, a complete truncal vagotomy results in denervation of the stomach, liver, gallbladder, pancreas, small intestine, and proximal large intestine.
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As the gastric antral pump is denervated, a concomitant gastric drainage (pyloroplasty, gastrojejunostomy) or resective (antrectomy) procedure is recommended.
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; this 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 toward the gastrohepatic ligament. ( Figure 9-3 )
