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Bilateral resection of segments of the vagus nerves in the region of the lower esophagus is a key component in treating intractable duodenal or gastrojejunal ulcers. The motor paralysis and resultant gastric retention that follow truncal vagotomy alone make it mandatory that a concomitant gastric resection or drainage procedure, such as pyloroplasty or an antrally placed gastroenterostomy, be performed. Gastrojejunal or stomal ulcers following a previous gastrectomy or gastrojejunostomy show a favorable response to vagotomy. The use of vagotomy to control the cephalic phase of secretion is preferred when it is desirable to retain as much gastric capacity as possible because of the preoperative nutritional status of the patient with duodenal ulcer. In females and in those individuals below their ideal weight preoperatively, controlling the acid factor by vagotomy followed by pyloroplasty, posterior gastroenterostomy, or hemigastrectomy should be seriously considered. Controlling the acid factor by vagotomy has been used in combination with other procedures in managing chronic recurrent pancreatitis. Serum gastrin levels should be determined.
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There are two vagal trunks—the anterior or left vagus nerve, which lies along the anterior wall of the esophagus, and the posterior or right vagus nerve, which is sometimes overlooked since it is more easily separated from the esophagus. The vagus nerves may be divided 5 to 7 cm above the esophageal junction (truncal vagotomy), divided below the celiac and hepatic branches (selective vagotomy), or divided so that only the branches to the upper two-thirds of the stomach are interrupted, while the nerves of Latarjet, innervating the antrum or lower one-third, as well as the celiac and hepatic branches, are retained (proximal gastric vagotomy).
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A good exposure of the lower end of the esophagus is essential and sometimes requires removal of the xiphoid as well as mobilization of the left lobe of the liver. The vagal nerves should be identified and divided as far from the esophagogastric junction as possible (Figure 1). Sections of these trunks should be sent to the pathologist for microscopic evidence that at least two vagus nerves have been divided. Whether silver clips or ligatures are applied to both ends of each nerve is the choice of the individual surgeon. It may be advisable to ligate the posterior nerve to control possible oozing that may take place in the mediastinum. The esophagus should be carefully inspected, and the area behind the esophagus, in particular, should be searched as the esophagus ...