Vagotomy Location in Billroth II Surgery
When performing a vagotomy as part of Billroth II surgery, the vagus nerves are transected at the distal esophagus, typically at or just above the level of the diaphragmatic hiatus, resulting in a truncal vagotomy that divides both the anterior and posterior vagal trunks before they give off their hepatic and celiac branches. 1
Anatomical Location and Technique
The vagotomy is performed on the distal thoracic esophagus where the vagus nerves run as distinct anterior and posterior trunks alongside the esophagus. 1 This truncal approach differs from selective vagotomy, which would preserve the hepatic branch of the anterior vagus and the celiac branch of the posterior vagus. 2
Specific Technical Points:
- Both vagal trunks are divided bilaterally during the procedure 1
- The transection occurs before the vagal branches diverge to supply the liver and celiac axis 2
- In videothoracoscopic approaches, the bilateral truncal vagotomy can be completed in approximately 45 minutes 1
Rationale for Truncal Vagotomy with Billroth II
The truncal vagotomy is specifically chosen when performing Billroth II reconstruction because:
- Pylorospasm concerns are eliminated since the pylorus is resected as part of the gastric resection 1
- Unlike procedures preserving the pylorus, no drainage procedure is required when the pylorus has been removed 1
- The procedure effectively reduces acid production to promote ulcer healing 1
Clinical Context
This approach is most commonly employed in:
- Recurrent ulceration after previous gastric surgery 1
- Duodenal ulcers requiring gastric resection 3, 4
- Cases where Billroth II reconstruction is specifically chosen over Billroth I 3, 4
Important Caveat:
When the pylorus is preserved (as in some gastric procedures), truncal vagotomy causes pylorospasm in approximately 20% of cases, necessitating a synchronous drainage procedure. 1 However, this is not relevant to Billroth II surgery where the pylorus is resected.
Contrast with Selective Vagotomy
If vagal nerve preservation were attempted (not standard in Billroth II), the hepatic branch of the anterior vagus and celiac branch of the posterior vagus would be the targets for preservation to reduce postoperative complications like gallstone formation, diarrhea, and weight loss. 2 However, this selective approach is not typically performed with Billroth II reconstruction.