vago thomas

8/12/2019 Vago Thomas

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VagotomyThomas Kristianto


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Background

Vagotomy is the surgical cuttingfrom the vagus nerve to lessen acid

secretion within the stomach.

Vagotomy is an essential component of

surgical management of peptic (duodenal

and gastric) ulcer disease (PUD)


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The basic types of vagotomy are as follows:

Truncal vagotomy(TV)

Selective vagotomy(SV)

Highly selective vagotomy(HSV)

All types of vagotomy can be performed at

open surgery (laparotomy) or using minimally

invasive surgery (laparoscopy). A vagotomy isconducted under general anesthesia.


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Zeman, M. et al., Speciln chirurgie, ISBN 80-7262-260-9, 2004

Vagotomy


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Truncal vagotomy (TV):

This procedure includes

division of the main trunk

of the vagus (including itsceliac/hepatic branch) and

denervation of the

pylorus;therefore, a

pyloric drainageprocedure, such as pyloric

dilatation or disruption

(pyloromyotomy or

pyloroplasty) or

gastrojejunostomy (GJ), is

needed. This procedure

also denervates the liver,

biliary tree, pancreas, and

small and large bowel.

Selective vagotomy (SV):

This procedure includes

division of the anterior and

posterior gastric nerves ofLatarjet only (after

celiac/hepatic branches have

been given off). It also

denervates the pylorus and,therefore, a pyloric drainage

procedure is needed. It does

not denervate the liver,

biliary tree, pancreas, or

small and large bowel. This

procedure is rarely

performed.


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Highly selective vagotomy (HSV):

This procedure includes denervation of only the

fundus and body (parietal cell containing areas) of

the stomach (also called parietal cell vagotomy[PCV]). It preserves the nerve supply of the

antrum and pylorus; a pyloric drainage procedure

is not needed. It does not denervate the liver,

biliary tree, pancreas, or small and large bowel.

This procedure is also called proximal gastric

vagotomy (PGV).


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Indication

Vagotomy is indicated as management of peptic ulcerdisease (PUD) in the following cases:

Elective - Failure of medical treatment (with the availability of

effective acid suppression with H2-receptor antagonists andproton pump inhibitors, however, this indication has virtually

become nonexistent

Semi-elective- Pyloric stenosis (obstruction) due to PUD

Emergency - Upper GI bleeding due to PUD or stress gastriculcers (erosive gastric mucosal disease) or perforated PUD that is

causing peritonitis

Incidental vagotomy - An inadvertent vagotomy performed

during esophagectomy


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Anatomy Arterial blood supply

Lymphatic drainage Nerve supply


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Anatomy and physiology

The duodenum connects the stomach to the

jejunum, which is the second part of the

small bowel


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It is 20 cm (8 inches) in length and divided into four parts

The duodenum is retroperitoneal (has peritoneum, the thin layerof tissue that lines the abdominal cavity) only on the anterior

(front) side; fixed in location; wraps around the head, neck and

body of the pancreas; and the superior mesenteric artery and vein

(major blood vessels for the bowel) pass anterior to the 3rd

portion

The ampulla of Vater (entrance site into duodenum of joined

common bile duct and pancreatic duct) enters the medial

(towards the midline) side of the 2nd portion of the duodenum

The accessory pancreatic duct enters slightly higher in the medial

wall of the duodenum


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The ligament of Treitz (a supporting band

of peritoneum and muscle fibers) marks the

point between the duodenum and jejunumThe wall of the small bowel (Figure 2) is

made up of four layers:


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The mucosa is the inner most layer and composed of

small fingerlike projections (villi) covered with a single

layer of cells (epithelium). Beneath the epithelium is athin layer of connective tissue (lamina propria) and

muscle (muscularis mucosa)

The submucosa is a thin strong layer containing

connective tissue, vessels, nerves and lymphatics

The muscularis propria is composed of smooth muscle

that has a thicker circular inner layer and thin outer

layer that runs lengthwise

The serosa is the single cell thick outer layer similar to

the peritoneum (visceral peritoneum)


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The duodenum produces many hormones that help

regulate digestion. Liver bile and pancreaticsecretions are added to the bowel through the

ampulla of Vater. The actual passage and presence

of food in the duodenum starts the flow of

hormones, bile and pancreatic secretions. By thetime food leaves the duodenum most of the

ingredients necessary for digestion have been

added. Little digestion and absorption (passage of

nutrients from the bowel into the blood) take place

in the duodenum.


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Preparation

A blood transfusion may be needed for patients with ableeding peptic ulcer.

Resuscitation, fluid and electrolyte imbalance correction,

and antibiotics should be administered, as needed, in

patients with perforated peptic ulcer. Patients with pyloric stenosis due to peptic ulcer have

dehydration, alkalosis, and hypokalemia, which need

correction with normal saline and potassium chloride.

Gastric aspiration and lavage is required to decompress the

dilated stomach.

A nasogastric tube allows easier intraoperative

identification (palpation) of the esophagus.


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potitioning

The patient is placed in the supine position;

a slight reverse Trendelenburg (head up)

may be used in order to displace theintestines caudad.

The patient is placed in a right lateral (left

up) for the thoracic approach.


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Highly selective vagotomy

Highly selective parietal cell vagotomy (division of the

fibers of the vagus nerve that go to the body of the

stomach) This interrupts acid secretion of the stomach.

The anterior and posterior

vagus nerves are seen lying

on the stomach

The branches of the vagus

nerves going to the

stomach are cut to givethe selective vagotomy


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The main vagal trunks are dissected and looped as

described above.

The hepatic branch of the anterior vagus and celiac branch

of the posterior vagus are identified and carefully

preserved; the anterior and posterior gastric nerves ofLatarjet (which lie about 1-2 cm from the lesser curve) are

also identified and carefully preserved.

The greater curvature of the stomach is retracted

downward and to the left. The anterior layer of the lesser (gastrohepatic) omentum is

incised close to the lesser curve, taking care not to injure

the vascular arcade formed by the left and right gastric

vessels and the anterior gastric nerve of Latarjet.


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Branches of nerves and vessels (which travel together) going toward

the stomach wall are ligated and divided in bits and pieces proximal

to the cardia to the incisura angularis (which lies on the lesser curve

about 6-7 cm proximal to the pylorus), taking care to identify andpreserve at least 3 terminal branches (crow foot) of the anterior

gastric nerve of Latarjet, which supply the antrum and the pylorus.

This dissection is kept as close to the stomach as possible.

The greater (gastrocolic) omentum is divided 1-2 cm from the

greater curve, taking care not to injure the vascular arcade formedby the left and right gastroepiploic vessels, and the lesser sac

(behind the stomach and in front of the pancreas) is entered.

The stomach is turned upward and to the right, and its posterior

surface is exposed.

The posterior layer of the lesser (gastrohepatic) omentum is incised

close to the lesser curve, taking care not to injure the vascular arcade

formed by the left and right gastric vessels and the posterior gastric

nerve of Latarjet.


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Branches of nerves and vessels (which travel together) going

toward the stomach wall are ligated and divided in bits and

pieces from the cardia to the incisura angularis (which lies on

the lesser curve about 6-7 cm proximal to the pylorus), takingcare to identify and preserve at least 3 terminal branches (crow

foot) of posterior gastric nerve of Latarjet, which supply the

antrum and the pylorus. This dissection is kept as close to the

stomach as possible. The lower 6-7 cm of esophagus is cleared of all nerve

branches. A posterior gastric branch of the right vagus, called

the criminal nerve of Grassi (which traverses to the left and

supplies the cardia and the fundus of the stomach) is looked for

and divided. The main vagal trunks that had been looped

earlier are carefully preserved.


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In HSV, the main (right and left) vagal trunks, anterior and

posterior gastric nerves of Latarjet (which lie at a distance

of about 1-2 cm from the lesser curve), and at least 3

terminal branches (crow foot) of the anterior and posteriorgastric nerves of Latarjet, which supply the antrum and the

pylorus, are preserved. Only nerve branches to the

esophagus, cardia, fundus, and body are divided.

The bared lesser curve may be reperitonealized by closingthe anterior and posterior layers of the lesser omentum.

Alternatively, it can be covered with omentum. Some

surgeons, however, leave it bare as it is.


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Vagotomy and Antrectomy

The lines of incision to

remove the lower portion

of the stomach (antrum),

pylorus, and a small

amount of duodenum. The

vagus nerves are also cut(truncal vagotomy)

The bowel is reconstructed by

closing the end of the duodenum

and bringing up a loop of

jejunum to anastomose to the

stomach. This is called a Billroth

II reconstruction.


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Keuntungan dari vagotomy dan antrektomi

adalah risiko rendah terjadinya kekambuhan

ulkus dan penerapan operasi pada pasiendengan ulkus peptikum dengan komplikasi

(perdarahan duodenum dan ulkus gaster,

obstruksi ulkus peptikum, ulkus gaster yangtidak sembuh, dan ulkus rekuren)


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Kerugian dari operasi ini adalah memiliki

mortalitas yang tinggi dibanding dengan

Highly Selective Vagotomy atauVagotomy+Drainase.

Setelah antrktmy, gastrointestinal

disambung kembali, baik melalui billroth Igastroduodenostomi atau bilroth II loop

gastrojejunostomi


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Post Vagotomy syndrome

Highly selective vagotomy aims to maintain the nerves of

Latarjet(branches of the vagus nerve which supply the pyloric

sphincter) and obviate the need for an accompanying drainage

procedure (usually pyloroplasty).

Complications afterwards include:

Steatorrhoea and diarrhoea, which are common after vagotomy

(although this is less of a problem after highly selective vagotomy).

Often such symptoms are transient or episodic. However, in about2% of cases symptoms are severe or persistent.

Stomal ulceration, which can occur particularly if the vagotomy is

incomplete.


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Komplikasi

Perforasi

Penetrasi tukak yang mengenai pankrreas

Obstruksi outlet

Intraktibilitas

Keganasan dalam duodenum


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Prognosis

Prognosis tergantung dari perjalanan

penyakit dan komplikasi yang terjadi.

Kebanyakan pasien berhasil diobati denganeradikasi infeksi H.pylori, menghindari

NSAID, dan penggunaan yang tepat

antisekresi


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TERIMA KASIH

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