Vagotomy is NOT routinely performed in modern perforated peptic ulcer (PPUD) surgery
The current standard of care for perforated peptic ulcer is simple closure with or without omental patch—vagotomy is no longer recommended as a routine adjunct to perforation repair 1.
Why Vagotomy Was Historically Performed
Vagotomy was historically added to perforation repair to:
- Reduce acid secretion and prevent ulcer recurrence
- Alter the natural history of peptic ulcer disease, which had high recurrence rates (36.6% at 3 years) after simple closure alone 2
- Provide definitive treatment in the pre-H. pylori era when medical management was inadequate
Studies from the 1980s-1990s showed that proximal gastric vagotomy (PGV) with perforation closure reduced symptomatic recurrence to 10.6% compared to 36.6% with closure alone 2, with minimal dumping or diarrhea 3, 4.
Why Vagotomy Is No Longer Done
The practice has fundamentally changed due to:
1. Medical Management Revolution
- H. pylori eradication now cures the underlying disease in most cases 5
- Proton pump inhibitors (PPIs) provide effective long-term acid suppression
- Elective vagotomy has become "nearly obsolete" 6
2. Increased Operative Risk Without Benefit
The 2020 WSES guidelines 1 make no mention of vagotomy in their comprehensive recommendations for PPUD surgery, focusing instead on:
- Simple repair for perforations <2 cm
- Laparoscopic approach when feasible
- Omental patch only if needed for large/friable perforations
3. Evidence Against Routine Use
A large NSQIP database study 7 found:
- For perforated ulcers: vagotomy/drainage produced similar outcomes to local procedures but required significantly longer hospitalization
- Vagotomy/gastric resection was associated with significantly greater morbidity for both bleeding and perforation
The Exception: Bleeding Peptic Ulcers
Vagotomy/drainage may still have a role in bleeding (not perforated) peptic ulcers requiring emergency surgery, where it was associated with significantly lower postoperative mortality than simple oversew 7. However, this is a different clinical scenario than PPUD.
Current Approach to PPUD
The modern algorithm is:
- Immediate surgical repair (laparoscopic preferred) with simple closure ± omental patch 8, 9
- Postoperative H. pylori testing and eradication if positive
- Long-term PPI therapy as needed
- Reserve definitive procedures only for the rare patient with persistent ulcers despite medical management 5
Critical Caveat
Few surgeons performing emergency PPUD surgery today have experience with vagotomy 5. Attempting an unfamiliar vagotomy in an emergency setting increases operative time and complication risk without clear benefit when effective medical therapy can address recurrence postoperatively. Simple suture followed by medical treatment is the safest option 5.