The region of the esophagus is palpated. The peritoneum immediately over the esophagus is grasped with a forceps, and an incision is made in the peritoneum at right angles to the long axis of the esophagus (figure 5). The incision may be extended laterally to ensure mobilization of the fundus of the stomach. Curved scissors are then directed gently upward to free the anterior surface of the esophagus from the surrounding tissue. This can be done by blunt dissection, using the index finger (figure 6). The dissection should carry posteriorly and laterally along both crura as far as necessary to allow the posterior esophagus to be dissected. Sometimes it is helpful to divide the left side of the crura and the proximal attachments to the stomach. After an inch or more of the anterior wall of the esophagus has been freed from the surrounding structures, the index finger should be introduced beneath the esophagus from the left side. It is frequently necessary to loosen some adhesions in this area by sharp dissection. Usually, little difficulty is encountered in gently passing the index finger beneath the esophagus and its indwelling nasogastric tube and completely freeing it from the surrounding structures. Just to the right of the esophagus, the index finger will usually encounter resistance from the uppermost limit of the hepatogastric ligament (figure 7). This portion of the structure should be divided, since its division affords more mobilization of the esophagus and tends to provide exposure of the posterior or right vagus nerve. The major portion of the hepatogastric ligament in this area is quite avascular and thin, so that it can be perforated easily with scissors or electrocautery. If electrocautery is not available then a pair of right-angle clamps is then applied to the uppermost portion of the ligament, and the contents of these clamps divided with long, curved scissors (figure 8). This exposes the region posterior to the esophagus and ensures adequate exposure of the hiatal region.
Downward traction is maintained on the esophagus while it is further freed from the surrounding structures by blunt dissection with the index finger. The vagus nerves are not always easily identified, and their location is more quickly discovered by palpation (figure 9). As the tip of the index finger is passed over the esophagus, the tense wirelike structure of the nerve is easily identified. It should be remembered that one or more smaller nerves may be found, both anteriorly and posteriorly, in addition to the large left and right vagus nerves. Additional small filaments may be seen crossing over the surface of the esophagus in its long axis. The left vagus nerve is usually located on the anterior surface of the esophagus, a little to the left of the midline, while the right vagus nerve is usually located a little to the right of the midline, posteriorly (figures 10 and 10a). The left vagus is then grasped with a fine clamp, and is dissected free from the adjacent structures (figure 11). The nerve can be separated from the esophagus easily by blunt dissection with the surgeon’s index finger. It is usually possible to free at least 6 cm of the nerve (figure 12). The nerve is clipped and is divided with long, curved scissors as high as possible. It is usually necessary to ligate the gastric ends of the vagus nerve as well. (figure 13). The use of clips at the point where the vagus nerves divide minimized bleeding and serves to identify the procedures on subsequent roentgenograms. After the left vagus nerve has been resected, the esophagus is rotated slightly, and the traction is directed more to the left. It is usually not difficult to dissect free the right or posterior vagus nerve with the index finger or nerve hook (figure 14). In some instances it has been found that the nerve has been separated from the esophagus at the time it was initially freed from the surrounding structures. The nerve, in such instances, appears to be resting against the posterior wall of the esophageal hiatus. The tendency to displace the right vagus nerve posteriorly during the blind process of freeing the esophagus no doubt accounts for the fact that this large nerve may be overlooked while all filaments about the esophagus are meticulously divided. This is the nerve most commonly found to be intact at the time of secondary exploration for a clinical failure of the vagotomy. A careful search should be made for additional nerves, since it is not uncommon to find more than one. A minimum of 6 cm of the right or posterior vagus nerve should be resected (figure 15). Although the nerves may be clearly identified, the surgeon should not be satisfied until another careful search has been made completely around the esophagus. By traction on the esophagus and by direct palpation, any constricting band should be freed and resected, and a careful inspection should be made throughout the circumference of the esophagus. The operator will find that many of the little filaments that he dissects, in the belief that they are nerves, will prove to be small blood vessels that will require ligation. A final survey should always be made to be absolutely certain that the large right vagus nerve has not been displaced posteriorly, thus escaping division. A frozen section examination may be obtained to verify that both nerves have been removed. Traction should be released and the esophagus allowed to return to its normal position. The area should be carefully inspected for bleeding. No effort is made to reapproximate the peritoneal cuff over the esophagus to the cuff of peritoneum at the junction of the esophagus with the stomach. Finally, the esophagus is retracted upward and to the left by a narrow S retractor in order to expose the crus of the diaphragm. Two to three of nonabsorbable sutures may be placed sut to approximate the crus of the diaphragm as in the repair of a hiatus hernia if the hiatus appears patulous (figures 16 and 17). Sufficient space about the esophagus must be retained to admit one finger or the passage of a 54 French or larger esophageal dilator into the stomach. All packs are removed from the abdomen, and the left lobe of the liver is returned to its normal position. It is not necessary to reapproximate the triangular ligament of the left lobe.
Vagotomy must always be accompanied either by a gastric resection or drainage of the antrum by posterior gastroenterostomy or division of the pylorus by pyloroplasty. Since gastric emptying may be unduly delayed following vagotomy, efficient gastric drainage by gastrostomy should be considered.