During a Nissen (Nissen fundoplication) crural dissection, which vagus nerve branch is most at risk, the left vagus, right vagus, or hepatic branch of the vagus?

From the Guidelines

During a Nissen fundoplication crural dissection, the left vagus nerve is most at risk due to its anatomical location on the anterior surface of the esophagus. The left vagus nerve typically lies on the anterior surface of the esophagus and can be inadvertently injured when dissecting the esophageal hiatus or when creating the fundoplication wrap. Some key points to consider during this procedure include:

• The left vagus nerve often courses along the lesser curvature of the stomach and anterior esophageal surface, directly in the surgical field, making it particularly vulnerable to injury 1.
• The right vagus nerve, which typically runs posteriorly along the esophagus, is somewhat more protected during the anterior dissection required for a Nissen procedure.
• The hepatic branch of the vagus, which branches from the anterior vagal trunk, is less commonly injured during standard fundoplication as it typically branches off higher and travels toward the liver, and its preservation is reported to contribute to improving postoperative quality of life through reducing post-gastrectomy gallstone formation, diarrhea and/or weight loss 1. Injury to the anterior vagal trunk can result in delayed gastric emptying, altered gastric acid secretion, and potential digestive dysfunction, highlighting the importance of careful identification and preservation of these neural structures during hiatal dissection for optimal postoperative gastrointestinal function.

From the Research

Nissen Crural Dissection and Vagus Nerve Considerations

During a Nissen fundoplication, crural dissection is a critical step that requires careful consideration of the surrounding anatomical structures, including the vagus nerves. The primary concern is to preserve the function of these nerves to maintain postoperative quality of life.

Vagus Nerve Branches at Risk

• The hepatic branch of the vagus is particularly relevant during Nissen fundoplication, as it may be at risk due to its location and the dissection required for the procedure 2.
• The left and right vagus nerves are also important considerations, but the specific risk to these nerves during crural dissection in the context of Nissen fundoplication is less clearly defined in the provided studies.
• Studies suggest that preserving the hepatic branch of the vagus nerve can have beneficial effects on postoperative biliary functions, such as shorter gallbladder emptying times 2.

Surgical Technique and Vagus Nerve Preservation

• The surgical technique for Nissen fundoplication involves careful dissection and preservation of both vagus nerves, followed by circumferential dissection of the esophagus and mobilization of the gastric fundus 3.
• While the preservation of the vagus nerves is important, one study found that isolating the vagus nerves from the fundoplication wrap did not significantly modify the postoperative outcome or reduce gastric emptying disturbances 4.