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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 Plate 16).

A careful evaluation of the adequacy and extent of the medical management is made. Secretion determination with continuous suction may be done to ascertain the gastric secretory status of the patient. Fasting serum gastrin levels are indicated. Proof of the presence of a duodenal ulcer and determination of the amount of gastric retention are established by endoscopy, by a barium meal, by fluoroscopy and roentgenologic studies, and by fasting aspirations through a stomach tube. Constant nasogastric suction is maintained during the operation.

General anesthesia, supplemented with curare for relaxation, is satisfactory. The insertion of an endotracheal tube provides smoother operating conditions for the surgeon and easy control of the airway for the anesthesiologist.

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.

The skin is prepared in the usual manner.

A high midline incision is extended up over the xiphoid and down to the region of the umbilicus (Figure 1). 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 next step is to mobilize the left lobe of the liver. This maneuver 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 ...

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