A practical guide written from the perspective of an Operating Room Nurse.
The workflows, surgeon preferences, and nursing tips presented in this article are based on the author’s real clinical experience. Surgical techniques and operating room practices may vary depending on the surgeon, hospital, and institutional protocols.
What is a Vagotomy?
A vagotomy is a surgical procedure that involves dividing branches of the vagus nerve to reduce gastric acid secretion.
Historically, vagotomy was one of the standard operations for treating refractory peptic ulcer disease before proton pump inhibitors (PPIs) and Helicobacter pylori eradication therapy became widely available.
Although it is rarely performed today, understanding vagotomy remains important because surgeons may encounter altered anatomy during revisional gastric surgery or historical cases.
📌Quick Facts
| Item | Details |
|---|---|
| Procedure | Vagotomy |
| Specialty | Upper Gastrointestinal Surgery |
| Purpose | Reduce gastric acid secretion |
| Main Indication | Refractory peptic ulcer disease |
| Common Types | Truncal Vagotomy, Highly Selective Vagotomy |
| Reconstruction Needed | Depends on procedure |
Types of Vagotomy
1. Truncal Vagotomy
Truncal vagotomy divides both the anterior and posterior vagal trunks at the distal esophagus.
Structures divided
- Anterior vagal trunk
- Posterior vagal trunk
Since this operation denervates the pylorus, gastric emptying becomes impaired.
Therefore, a drainage procedure is usually required.
Common combinations include:
- Pyloroplasty
- Gastrojejunostomy
- Antrectomy
2. Highly Selective Vagotomy (Parietal Cell Vagotomy)
Highly selective vagotomy preserves the nerves supplying the pylorus while selectively dividing only the vagal branches to the acid-producing proximal stomach.
Advantages include:
- Preservation of gastric emptying
- No drainage procedure required
- Lower incidence of dumping syndrome
The Latarjet nerve is carefully preserved while denervating the gastric body and fundus.
Surgical Anatomy
Understanding vagal anatomy is essential.
Important structures include:
- Anterior vagus nerve
- Posterior vagus nerve
- Hepatic branch
- Celiac branch
- Nerves of Latarjet
- Crow’s Foot branches
- Esophageal hiatus
- Right and left crura
The uploaded reference illustrates these important branches and the anatomical relationship around the distal esophagus and stomach.
🕒Surgical Procedure
Truncal Vagotomy
Step 1
Expose the distal esophagus through the esophageal hiatus.
Step 2
Identify the anterior vagal trunk.
Carefully isolate the nerve from surrounding tissues.
Step 3
Resect approximately 2–3 cm of the anterior vagus to minimize the risk of reinnervation.
Step 4
Identify the posterior vagal trunk by rotating the esophagus.
Divide another 2–3 cm segment.
Step 5
Inspect for accessory branches.
Failure to divide accessory vagal branches may result in incomplete vagotomy.
Step 6
Approximate the diaphragmatic crura to prevent postoperative hiatal hernia while avoiding excessive narrowing of the esophagus.
Highly Selective Vagotomy
Step 1
Identify both anterior and posterior vagal trunks.
Step 2
Locate the Crow’s Foot near the lesser curvature.
Step 3
Preserve the nerves of Latarjet.
These nerves maintain pyloric function.
Step 4
Divide only the branches supplying the proximal stomach.
Step 5
Continue dissection approximately 6–7 cm proximal to the pylorus while preserving distal innervation.
The uploaded surgical illustrations demonstrate preservation of the Latarjet nerve and selective denervation of the proximal stomach.
Instruments Commonly Used
- DeBakey Forceps
- Metzenbaum Scissors
- Right Angle Clamp
- Peanut Dissector
- Electrocautery
- Fine Vascular Clips
- Needle Holder
- Suction Device
✅OR Nurse Checklist
Before nerve division:
☐ Confirm anterior vagus
☐ Confirm posterior vagus
☐ Identify hepatic branch
☐ Identify celiac branch
☐ Verify esophageal exposure
During surgery:
☐ Maintain clear visualization
☐ Protect surrounding vessels
☐ Handle vagal branches gently
☐ Count divided nerve segments
After completion:
☐ Inspect hemostasis
☐ Check crural repair
☐ Confirm preservation of Latarjet nerve (Highly Selective Vagotomy)
⚠️Common Pitfalls
Incomplete Vagotomy
Failure to identify accessory vagal branches may lead to persistent acid secretion.
Esophageal Injury
Aggressive dissection around the distal esophagus increases the risk of perforation.
Injury to Hepatic Branch
Damage may result in biliary dysfunction.
Injury to the Latarjet Nerve
Can impair gastric emptying even after highly selective vagotomy.
Excessive Hiatal Closure
Over-tightening the crura may produce postoperative dysphagia.
💎Pearls from the Operating Room
- Always identify the anterior vagus before searching for the posterior trunk.
- Rotate the esophagus gently to expose the posterior vagus.
- Preserve the hepatic branch whenever possible.
- During highly selective vagotomy, stay close to the gastric wall.
- Confirm preservation of the nerves of Latarjet before completing the operation.
Clinical Significance Today
Although vagotomy has become uncommon due to effective medical therapy for peptic ulcer disease, surgeons should still recognize the procedure because:
- Revisional gastric surgery may reveal previous vagotomy.
- Knowledge of vagal anatomy remains essential during esophageal and gastric operations.
- Understanding gastric innervation helps prevent unintended nerve injury.
Frequently Asked Questions
Is vagotomy still performed today?
Rarely. Most peptic ulcers are treated medically with proton pump inhibitors and Helicobacter pylori eradication.
Why is pyloroplasty often combined with truncal vagotomy?
Because truncal vagotomy denervates the pylorus, gastric emptying becomes impaired.
What is the major advantage of highly selective vagotomy?
It preserves pyloric innervation and maintains more normal gastric emptying.
Which nerve must be preserved during highly selective vagotomy?
The nerves of Latarjet.
Conclusion
Vagotomy is an important historical procedure in upper gastrointestinal surgery and remains highly relevant for understanding gastric neuroanatomy. Mastery of the vagal branches, careful identification of the anterior and posterior trunks, and preservation of critical structures such as the Latarjet nerve are essential for safe surgical practice.
Understanding these principles enables operating room nurses and surgical trainees to anticipate operative steps, recognize key anatomical landmarks, and provide effective intraoperative support.
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Learn the anatomy, surgical technique, indications, OR nursing tips, and key differences between truncal vagotomy and highly selective vagotomy.