Plate 18
Figure 17

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 ...

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