The vagus nerves run along the esophagus and serve many functions including helping the stomach to secrete acid and to empty its contents. Vagotomy, or cutting of the vagus nerve, is a surgical procedure to relieve excess acid secretion. Among many functions, the right and left vagus nerves along the esophagus assist with gastric acid secretion and gastric emptying. Overstimulation of these nerves results in excess acid production, eventually leading to the formation of ulcers.
When medication (such as antacids, H2 blockers, and proton pump inhibitors), does not relieve the acid excess, or when the stomach ulcer has reached a critical condition, surgical removal of the vagus nerves may be necessary.
Traditional vagotomies are performed as open surgery under general anesthesia, requiring about one week in the hospital and a six-week recovery period. Modern laparoscopy (microsurgery) makes it possible to use minimally invasive procedures, reducing the pain, risks, and length of recovery. Patients may leave the hospital after only 5 days (or sooner) and resume work in about ten.
The procedure is also a last resort in cases where traditional means such as medication and diet change are having no effect. Vagotomies are most often performed in emergencies such as bleeding or perforated ulcers. Most patients experience a normal recovery.
Detailed Description
Whether open or laparoscopic, the vagotomy is performed while the patient is under general anesthesia.
To clear the view during microsurgery, the abdomen is inflated with a gas (carbon dioxide). A laparoscope connected to a minicamera is inserted through a small incision at the umbilicus (navel). The miniature camera transmits a large, detailed view to the surgeon. Three or four more small incisions are made for the insertion of microsurgical instruments.
Often, necessary related surgeries can be performed at the same time. For example, if a part of the stomach is past saving, it may be removed during the vagotomy. Also, vagotomy changes the way in which the stomach empties its contents into the intestinal tract. To ease this, a drainage procedure called pyloroplasty may be performed at the same time as the vagotomy to enlarge the passage into the small intestine.
Four types of vagotomy may be performed laparoscopically. Each corresponds to a form of open vagotomy.
Truncal vagotomy divides the main vagal trunks, which also leads to denervation of the pancreas, small intestine, proximal colon, and hepatobiliary tree (gallbladder, bile ducts, liver). Vagotomy can reduce basal levels of acid secretion by up to 80% and stimulated acid secretion by up to 50%, but as many as a third of patients will have long-term adverse gastrointestinal side effects after the procedure, e.g., weight loss, chronic diarrhea, and cramps.
Selective vagotomy attempts to preserve the innervation of the pancreas, small intestine, proximal colon, and hepatobiliary tree. It was hoped that this would decrease the post-operative side effects of the truncal vagotomy. However, studies have indicated that the outcomes from this procedure were not better than a traditional truncal vagotomy, and it has fallen out of favor.
Highly selective vagotomy (HSV) reduces nerve sensitivity to stimulation, and therefore excess acid, by blocking nerve endings and diverting nerve branches only in the body (fundus) of the stomach. HSV therefore does not require a pyloroplasty. Much fewer patients experience the adverse gastrointestinal side effects after this form of the surgery. However, there does appear to be a higher rate of ulcer recurrence in patients who undergo this procedure versus the truncal vagotomy population. Most surgeons believe that the benefits in decrease of postoperative side effects far outweigh the risks of recurrent ulcers (the recurrence rate is about 10%).
Posterior truncal vagotomy with anterior seromyotomy (Taylor procedure) divides one vagal trunk while preserving the other. This procedure does not require a pyloroplasty. It appears to reduce acid secretion levels by a smaller amount than the truncal vagotomy, but this procedure is much simpler to perform and does not produce the adverse postoperative gastrointestinal side effects of a truncal vagotomy.There is also a thoracoscopic form of vagotomy (and a corresponding open thoracic vagotomy) to reach the upper portions of the vagus nerves.
Benefits of Laparoscopic Vagotomy
Over recent years, laparoscopy has largely displaced traditional open surgery as an option for vagotomies. Among the substantial benefits of laparoscopic vagotomy are the following:
Several tiny scars (scarcely visible after a few months) instead of a single large scar on the abdomen
Reduced hospital stay – only a few days for most patients
Less pain after the operation
A brief recovery period – a matter of days, not weeks – and a rapid return to normal activity.
Last updated: 06-Jun-03
