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INDICATIONS

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The long-term results of vagotomy are closely related to the completeness of the vagotomy and to efficient drainage or resection of the antrum (see Chapter 22).

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PREOPERATIVE PREPARATION

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A careful evaluation of the adequacy and extent of the medical management is made. Proton pump inhibitors are effective in most patients and smoking cessation and Helicobacter Pylori eradication are important steps in medical management prior to operation. Obtaining fasting serum gastrin levels may be indicated. Persistent ulcer despite appropriate therapy may indicate the need for surgery. The laparoscopic approach is straightforward and should be considered.

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ANESTHESIA

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General anesthesia with muscle relaxation is necessary. The insertion of an endotracheal tube provides smoother operating conditions for the surgeon and easy control of the airway for the anesthesiologist. An orogastric or nasogastric tube should be inserted to empty the stomach and allow palpation for the esophagus.

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POSITION

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The patient is placed flat on the operating table, with the foot of the table lowered to permit the contents of the abdomen to gravitate toward the pelvis.

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OPERATIVE PREPARATION

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The skin is prepared in the usual manner.

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INCISION AND EXPOSURE

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A high midline incision is extended up over the xiphoid and down to the region of the umbilicus. In some patients the exposure is greatly enhanced by removal of a long xiphoid process. A thorough exploration of the abdomen is carried out, including visualization of the site of the ulcer. The location of the ulcer, especially if it is near the common duct, the extent of the inflammatory reaction, and the patient’s general condition should all be taken into consideration in evaluating the risk of gastric resection in comparison to a more conservative drainage procedure. The anatomy of the vagus nerve is shown in figure 1.

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It may be necessary to mobilize the left lobe of the liver, alternatively a mechanical retractor (padded by a gauze sponge) can retract the left lobe superiorly. Mobilization is especially useful in obese patients where good exposure enhances the probability of complete vagotomy. If the operator stands on the right side of the patient, it is usually easier to grasp the left lobe of the liver with the right hand and with the index finger to define the limits of the thin, relatively avascular left triangular ligament of the left lobe of the liver. In many instances the tip of the left lobe extends quite far to the left (figure 2). By downward traction on the left lobe of the liver, and with the index finger beneath the triangular ligament to define its limits and to protect the underlying structures, the triangular ligament is divided with a long electrocautery probe or curved scissors. The assistant stands on the patient’s left ...

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