Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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CHAPTER 31 • Truncal Vagotomy 329

Incising peritoneum

FIGURE 31–3

vagus nerve

Incise peritoneum

over esophagus

FIGURE 31–2

Posterior

vagus nerve

FIGURE 31–1

330 Section IV • The Abdomen

◆ Once the peritoneum is incised, the index ﬁ nger is placed around the esophagus to encircle

it at the hiatus. Care should be taken to pass the ﬁ nger around the esophagus above the di-

aphragm to ensure that the posterior vagus is included in this maneuver. A Penrose drain is

then normally placed around the distal esophagus, and the anterior vagus nerve is identi-

ﬁ ed lying in the substance of the anterior esophagus (Figure 31-4).

◆ The anterior vagus nerve is then dissected and freed from the underlying esophagus

(Figure 31-5). In performing the truncal vagotomy, we place small metal clips on the vagus

nerve and excise a 2-cm segment between the clips. Excised vagal segments are sent for

pathologic examination of permanent sections (Figure 31-6).

◆ Traction is placed on the Penrose drain and the posterior vagus nerve identiﬁ ed (Figure 31-7).

◆ The procedure is repeated for the larger posterior nerve. Clips are placed and at least a

2-cm segment of the nerve is excised.

Anterior vagus nerve

FIGURE 31–4

CHAPTER 31 • Truncal Vagotomy 331

Mobilizing vagus nerve

FIGURE 31–5

Clipping anterior vagus nerve

FIGURE 31–6

FIGURE 31–7

332 Section IV • The Abdomen

◆ Care should be taken to identify and divide any accessory vagal ﬁ bers. As many as ﬁ ve

accessory vagal trunks have been reported, but most individuals have only two main trunks

(Figure 31-8).

◆ A drainage procedure such as pyloroplasty or gastroenterostomy is then used to complete

the procedure.

3. CLOSING

◆ The midline incision is closed in the standard fashion.

STEP 4: POSTOPERATIVE CARE

◆ A nasogastric tube is placed to suction, and when return of bowel function is noted, the

nasogastric tube is removed and clear liquids started.

STEP 5: PEARLS AND PITFALLS

◆ Truncal vagotomy is usually a safe and effective method for deﬁ nitive operative treatment of

ulcer disease. The trunks should be clearly identiﬁ ed and at least a 2-cm segment excised

and conﬁ rmed as nerve tissue by pathology.

Dividing

posterior vagus nerve

FIGURE 31–8

CHAPTER 31 • Truncal Vagotomy 333

◆ As noted, a careful assessment and identiﬁ cation of accessory vagal ﬁ bers should be under-

taken to prevent ulcer recurrence.

◆ Truncal vagotomy must always be accompanied by a drainage procedure to prevent gastric

stasis.

SELECTED REFERENCES

1. Mercer DW, Robinson EK: Stomach. In Townsend CM Jr (ed): Sabiston Textbook of Surgery: The Biological

Basis of Modern Surgical Practice, 18th ed. Philadelphia, Saunders, 2008, pp 1223-1277.

2. Thompson JC: Truncal vagotomy. In Thompson JC (ed): Atlas of Surgery of the Stomach, Duodenum and

Small Bowel. St Louis, Mosby-Year Book, 1992, pp 71-75.

334

STEP 1: SURGICAL ANATOMY

◆ Understanding the anatomy of the stomach and small bowel and determining whether an

antecolic or retrocolic approach is more appropriate are key points in this procedure.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Gastrojejunostomy can be performed in an antecolic fashion, which provides a quick and

effective method of connecting the distal stomach to the jejunum. In some instances, the

more direct path is a retrocolic anastomosis involving placement of the jejunal loop through

the transverse colon mesentery.

◆ Gastrojejunostomy is usually performed to bypass an obstructed distal stomach or duode-

num and provide relief. This is particularly useful in cancers that obstruct the duodenal

lumen or the distal stomach and are not resectable. Gastrojejunostomy should also be con-

sidered in the patient who requires a drainage procedure in whom a pyloroplasty may not

be safe because of chronic scarring of the duodenal bulb.

STEP 3: OPERATIVE STEPS

1. INCISION

◆ Using an open technique, an upper midline incision is usually performed. We are illustrating

the open technique in this chapter; however, gastrojejunostomy may be also accomplished

via laparoscopy.

CHAPTER

Gastrojejunostomy

B. Mark Evers

2. DISSECTION

◆ To create an antecolic gastrojejunostomy, the surgeon identiﬁ es a convenient section of dis-

tal stomach and a loop of jejunum that is easily maneuverable to the stomach distal to the

ligament of Treitz. A convenient location in the proximal jejunum is usually 15 to 20 cm

distal to the ligament of Treitz.

◆ A posterior row of seromuscular 3-0 silk sutures are placed in Lembert fashion to connect

the stomach and the jejunum. If a stapled anastomosis is to be performed, an enterotomy is

created using electrocautery; likewise, a gastrotomy is also performed to facilitate placement

of the stapler (Figure 32-1).

Creating an opening

in jejunum for stapler

FIGURE 32–1

CHAPTER 32 • Gastrojejunostomy 335

336 Section IV • The Abdomen

◆ The gastrointestinal anastomosis (GIA) stapling device is placed through the holes created

in the stomach and the jejunum, and the anastomosis is performed by ﬁ ring the stapler

(Figure 32-2).

◆ The enterotomy and gastroenterotomy are closed together using a transanastomotic (TA)

stapling device (Figure 32-3).

◆ Figure 32-4 demonstrates the complete antecolic gastrojejunostomy.

Stapler dividing excess

gastrojejunal tissue

Stapler used to create an

opening in stomach and jejunum

FIGURE 32 –2

FIGURE 32 –3

CHAPTER 32 • Gastrojejunostomy 337

◆ Figure 32-5 demonstrates the technique for a handsewn antecolic gastrojejunostomy. The

posterior row of Lembert 3-0 silk sutures are placed as noted previously. Electrocautery is

used to open the jejunum and the stomach, thereby creating the jejunal and gastric stomas

(Figure 32-6).

Jejunal serosa

FIGURE 32 –5

Complete antecolic

gastrojejunostomy

FIGURE 32 –4

338 Section IV • The Abdomen

◆ The inner layer of the anastomosis is performed using a running full-thickness absorbable suture,

such as 3-0 chromic or Vicryl, which is then carried anteriorly in a Connell fashion (Figure 32-7).

Jejunal stoma

Creating a gastric stoma

FIGURE 32 –6

Running closure

of posterior

mucosal layer

FIGURE 32 –7