The contents of these clamps are then ligated with 00 silk sutures. 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, but their location is more quickly discovered by palpation (Figure 9). As a 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 blunt nerve hook, such as the de Takats nerve dissector, and with curved scissors 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 crimped with a silver/tantalum clip and is divided with long, curved scissors as high as possible. It is unnecessary to ligate the ends of the vagus nerve unless bleeding occurs from the gastric end (Figure 13). The use of silver 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. In order to correct esophageal reflux associated with an incompetent lower esophageal sphincter, some surgeons perform fundoplication around the lower esophagus. The mobilized fundus is approximated by four or five sutures about the lower end of the esophagus with a large stomach tube in place to prevent excessive constriction. (See Plate 41.)
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 sutures of No. 1 silk may be placed 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 a 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.