Overview
Definition:
Truncal vagotomy involves the surgical division of the main trunks of the vagus nerve as they enter the abdomen
This procedure reduces gastric acid secretion by eliminating vagal stimulation of the parietal cells
Drainage procedures, such as pyloroplasty or gastrojejunostomy, are almost always performed concurrently to facilitate gastric emptying, as vagotomy alone can lead to delayed gastric emptying.
Epidemiology:
While historically a common procedure for peptic ulcer disease (PUD), its incidence has significantly decreased with the advent of proton pump inhibitors (PPIs) and H
pylori eradication therapy
It is now reserved for specific, refractory cases or complications of PUD.
Clinical Significance:
Understanding truncal vagotomy and drainage is crucial for surgical residents preparing for DNB and NEET SS examinations
It represents a classic surgical intervention for severe PUD, and knowledge of its indications, technique, and potential complications remains essential for managing complex gastrointestinal surgical cases.
Indications
Indications For Surgery:
Severe, intractable peptic ulcer disease refractory to medical management, including PPIs and H
pylori eradication
Recurrent peptic ulcers despite optimal medical therapy
Complicated peptic ulcer disease such as bleeding or perforation not amenable to simpler surgical repair or conservative management
Zollinger-Ellison syndrome (in conjunction with other modalities).
Patient Selection:
Careful patient selection is paramount
Patients must be medically fit for major abdominal surgery
Preoperative assessment for H
pylori infection and appropriate eradication therapy should be completed
Consideration of concomitant conditions affecting gastric motility is important.
Contraindications:
Severe comorbidities precluding surgery
Significant malnutrition
Patients who are poor surgical risks
Advanced gastric cancer
Primary indications for less invasive procedures.
Procedure Steps
Surgical Approach:
Typically performed via an upper midline laparotomy
Laparoscopic approaches are also feasible but may be more technically demanding for the vagotomy component.
Vagotomy Technique:
The anterior (a) and posterior (b) vagal trunks are identified as they cross the diaphragmatic hiatus into the abdomen
The anterior trunk is usually divided about 2-5 cm distal to the esophagus
The posterior trunk is similarly divided
Care must be taken to avoid injury to adjacent structures like the esophagus, aorta, and vena cava.
Drainage Procedure:
Pyloroplasty: This involves surgically widening the pylorus to improve gastric emptying
Common types include the Heineke-Mikulicz (longitudinal incision, transverse closure) and Jaboulay (gastroduodenostomy) pyloroplasty
Gastrojejunostomy (Billroth II type reconstruction): This creates a direct connection between the stomach and the jejunum, bypassing the pylorus.
Gastric Resection:
In some cases, particularly for duodenal ulcers, a highly selective vagotomy (preserving innervation to the pyloric sphincter) might be considered, but truncal vagotomy often necessitates a drainage procedure
For gastric ulcers, vagotomy may be combined with antrectomy or partial gastrectomy.
Postoperative Care
Immediate Postoperative Management:
Intensive monitoring in the recovery room
Pain management with intravenous analgesics
Intravenous fluid resuscitation and electrolyte monitoring
Nasogastric tube decompression to reduce gastric distension and aspirate residual gastric contents.
Dietary Advancement:
Initiate clear liquids once bowel sounds return and flatus is passed
Gradually advance to a soft diet, and then to a regular diet as tolerated
Patients may experience early satiety and postprandial fullness.
Monitoring For Complications:
Close observation for signs of anastomotic leak, bleeding, intra-abdominal infection, or delayed gastric emptying
Regular assessment of vital signs, abdominal examination, and fluid balance
Monitoring for electrolyte imbalances, especially hypokalemia and hypomagnesemia.
Complications
Early Complications:
Bleeding from the surgical site or residual ulcer
Gastric stasis or delayed gastric emptying leading to nausea, vomiting, and abdominal distension
Wound infection
Intra-abdominal abscess
Pneumonia
Atelectasis
Injury to adjacent organs (esophagus, spleen, pancreas).
Late Complications:
Dumping syndrome (early and late phases): characterized by postprandial symptoms like nausea, vomiting, abdominal cramps, diarrhea, palpitations, and sweating
Alkaline reflux gastritis: Bile reflux into the stomach causing epigastric pain and vomiting
Marginal ulcers (anastomotic ulcers): Ulcers forming at the gastrojejunal anastomosis, often due to inadequate vagotomy or persistent H
pylori infection
Diarrhea
Weight loss.
Prevention Strategies:
Meticulous surgical technique, including secure hemostasis and careful handling of tissues
Performing an appropriate drainage procedure to prevent gastric stasis
Adequate postoperative fluid and electrolyte management
Prompt diagnosis and management of H
pylori infection
Careful dietary modification and long-term follow-up for patients experiencing dumping syndrome or reflux symptoms.
Key Points
Exam Focus:
Understand the physiological basis of vagotomy (reduction of basal and stimulated acid secretion)
Differentiate between truncal and highly selective vagotomy
Recognize the absolute necessity of a drainage procedure with truncal vagotomy
Know the common complications like dumping syndrome and marginal ulcers and their management.
Clinical Pearls:
The choice of drainage procedure (pyloroplasty vs
gastrojejunostomy) depends on the location and extent of the ulcer and the surgeon's preference
Persistent symptoms post-vagotomy should prompt investigation for inadequate vagotomy (e.g., elevated basal acid output) or H
pylori reinfection.
Common Mistakes:
Omitting a drainage procedure with truncal vagotomy, leading to significant gastric stasis
Inadequate division of both vagal trunks
Misinterpreting symptoms of dumping syndrome as recurrence of ulcer disease
Failure to consider H
pylori in recurrent ulcers post-surgery.