What is the step-by-step procedure for a truncal vagotomy in a patient with severe peptic ulcer disease?

Truncal Vagotomy: Step-by-Step Surgical Procedure

Truncal vagotomy is now rarely performed as a standalone procedure for peptic ulcer disease, with its primary modern indication being emergency bleeding peptic ulcers refractory to endoscopic treatment, where it is combined with a drainage procedure. 1, 2

Modern Clinical Context

The role of truncal vagotomy has dramatically shifted from elective to emergency settings. For patients with intractable bleeding peptic ulcers after failed endoscopy and angioembolization, vagotomy with drainage demonstrates significantly lower mortality compared to simple ulcer oversewing alone. 1, 2 This applies particularly to large posterior duodenal ulcers with gastroduodenal artery bleeding. 1, 2

Surgical Approach Selection

Open Transabdominal Approach (Standard for Emergency Cases)

Open surgery remains the recommended approach for refractory bleeding peptic ulcer in emergency settings. 1, 2 This provides optimal access for both the vagotomy and management of the bleeding ulcer.

Thoracoscopic Approach (Limited Indications)

Thoracoscopic truncal vagotomy is reserved for highly selected cases, specifically recurrent ulceration after previous gastric surgery where intraabdominal access is complicated by adhesions or abscess. 3, 4 This approach has an operation time of approximately 45 minutes and minimal morbidity. 3

Step-by-Step Procedure: Open Transabdominal Truncal Vagotomy

1. Patient Positioning and Access

• Position patient supine under general anesthesia 5
• Perform upper midline laparotomy for optimal exposure 5
• Place self-retaining retractor to expose the esophageal hiatus 5

2. Exposure of the Esophageal Hiatus

• Retract the left lobe of the liver anteriorly and to the right 5
• Incise the gastrohepatic ligament (pars flaccida) to expose the esophagus 5
• Identify the anterior vagal trunk on the anterior surface of the distal esophagus 5
• Mobilize the distal esophagus by dividing the phrenoesophageal ligament 5

3. Identification and Division of Vagal Trunks

• Anterior vagus nerve: Identify the anterior trunk on the anterior esophageal surface, typically 1-2 cm above the gastroesophageal junction 5
• Isolate a 2-3 cm segment of the anterior vagus using blunt dissection 5
• Doubly ligate the nerve with non-absorbable suture and excise the intervening segment for histologic confirmation 5
• Posterior vagus nerve: Rotate the esophagus anteriorly to expose the posterior surface 5
• The posterior vagus lies more medially and posteriorly, often embedded in esophageal tissue 5
• Isolate, doubly ligate, and excise a 2-3 cm segment 5
• Critical step: Palpate the entire circumference of the distal esophagus to identify any additional vagal branches or criminal nerves of Grassi 5

4. Mandatory Drainage Procedure

• Truncal vagotomy causes pylorospasm in approximately 20% of cases, making a drainage procedure essential. 3, 5

For bleeding duodenal ulcers with gastroduodenal artery involvement:

• Perform longitudinal duodenotomy to visualize the ulcer base 1
• Execute triple-loop suturing of the gastroduodenal artery due to collateral blood supply from transverse pancreatic arteries 1
• Convert the duodenotomy to pyloroplasty (Heineke-Mikulicz or Finney technique) 6, 5

Alternative drainage options:

• Gastrojejunostomy (Roux-en-Y configuration preferred) 3, 5
• Double pyloroplasty for larger gastric outlet 6

5. Intraoperative Verification

• Consider intraoperative endoscopy if the bleeding source location is uncertain preoperatively 1
• Verify hemostasis at the ulcer site 1
• Ensure adequate drainage procedure patency 5

6. Closure and Drainage

• Place closed suction drain near the duodenal repair if performed 5
• Close the abdomen in standard fashion 5

Step-by-Step Procedure: Thoracoscopic Truncal Vagotomy

This approach is reserved exclusively for recurrent ulceration after previous gastric surgery where patients already have a drainage procedure in place. 3, 4

1. Patient Positioning

• Position patient in right lateral decubitus position 3, 4
• Single-lung ventilation of the right lung 4

2. Port Placement

• Place camera port in the 7th intercostal space, mid-axillary line 3, 4
• Insert two additional 5-10mm working ports 3, 4

3. Vagal Nerve Identification

• Identify the esophagus at the level of the inferior pulmonary vein 4
• Visualize both vagal trunks on the esophageal surface 3, 4

4. Bilateral Vagotomy

• Isolate and divide both anterior and posterior vagal trunks 3, 4
• Excise nerve segments for histologic confirmation 3
• Operation time approximately 45 minutes 3

Critical Considerations for Large or Complex Ulcers

For perforated or bleeding ulcers >2 cm in diameter, the surgical approach must be modified based on anatomical location. 1

Gastric Ulcers >2 cm:

• Perform gastric resection rather than simple closure, as 10-16% of perforated gastric ulcers harbor malignancy 1
• Send specimen for frozen section examination intraoperatively 1
• Antrectomy with Billroth I or II reconstruction is the standard approach 1

Duodenal Ulcers >2 cm:

• Assess proximity to ampulla of Vater and common bile duct 1
• Consider intraoperative cholangiography if anatomy is unclear 1
• Options include antrectomy with vagotomy, pyloric exclusion, or jejunal serosal patch 1
• Leak rates up to 12% occur with omental patch closure of large duodenal ulcers 1

Damage Control Approach for Unstable Patients

In patients with hemorrhagic shock and severe physiological derangement (hypothermia, coagulopathy, acidosis), abort the definitive procedure and perform damage control surgery. 1, 2

Damage control steps:

• Control hemorrhage with suture ligation only 1
• Perform pyloric exclusion with gastrostomy for decompression 1
• Place external biliary drainage via T-tube if needed 1
• Plan staged definitive repair after resuscitation 1

Essential Post-Operative Management

• Test all patients for Helicobacter pylori and provide eradication therapy if positive, as this reduces ulcer recurrence from 26% to near zero 1, 2
• Continue proton pump inhibitor therapy indefinitely 2
• Monitor for dumping syndrome (occurs in minority of patients) 6
• Perform follow-up endoscopy at 4-6 weeks 1

Critical Pitfalls to Avoid

• Never perform truncal vagotomy without a drainage procedure in the same operation, as pylorospasm occurs in 20% of cases 3
• Each hour of surgical delay increases mortality by 2.4%, so proceed expeditiously once the decision for surgery is made 1, 2
• Failure to perform triple-loop suturing of gastroduodenal artery bleeding risks rebleeding due to collateral circulation 1
• Missing the criminal nerve of Grassi (posterior gastric branch) leads to incomplete vagotomy and ulcer recurrence 5
• Attempting definitive resection (Whipple procedure) in peritonitis carries prohibitive mortality risk 1