transthoracic vagotomy

Transthoracic vagotomy has been widely used in the treatment of simple ulcer disease abroad. According to Dragstedt's experience in 800 cases of vagotomy, this method is considered to be an effective and safe surgical method that can replace duodenal resection for duodenal ulcer. Treatment of diseases: duodenal ulcer, gastric ulcer Indication Patients with gastric ulcers. Contraindications 1, with systemic diseases, can not tolerate surgery. 2, local infection, not suitable for surgery. Preoperative preparation Antibiotics are routinely used before surgery. Surgical procedure 1. Position, incision: supine position. The upper abdomen is cut from the xiphoid to the umbilicus, and the left rib arch cartilage can be cut if necessary. 2. Exposing the esophageal hiatus: After exploratory laparotomy, after the duodenal ulcer is confirmed, the left outer lobe of the liver is exposed, and the left triangular ligament and the coronary ligament are cut by hand or by pulling the hook. Note the ligation of the accessory hepatic vein from the diaphragm to the small blood vessels of the liver and the surface of the diaphragm. After covering with a gauze pad, pull the hook to pull the left lobe of the liver to the right to reveal the cardia and esophageal hiatus. 3. Cut the esophageal hiatus peritoneum: Touch the gastric tube placed before surgery, and confirm that it is the lower end of the cardia and esophagus. Cut the peritoneum below the peritoneal reflex of the esophageal hiatus. Be careful not to damage the infraorbital vein at the upper edge of the hiatus. Then, a segment of the esophagus is separated by a finger along the loose connective tissue around the esophagus. 4. Cutting off the vagus nerve: The vagus nerve anterior (left branch) usually closes to the anterior wall of the esophagus and goes slightly to the left side. It is usually seen after the peritoneum is cut and the esophagus is revealed. If you can't see it or if the oozing is unclear, you can pull the stomach down and tighten the esophagus. On the surface, you can feel a string-like strip, which is the vagus nerve. After separating it for about 3 to 5 cm, it was excised. Filament wire ligation is applied to the two ends. In order to prevent bleeding from neurotrophic blood vessels. 5. Cut off the vagus nerve and dry: use gauze strips or fingers to pull the esophagus to the left side, and loosen the connective tissue in the right posterior to the esophagus to find the vagus nerve (right branch). The posterior stem is different from the anterior trunk and often has a distance from the esophagus; it is hidden in the retroperitoneal tissue. After being found, a nerve of about 3 to 5 cm in length was isolated and excised. The two stumps were ligated with a thin wire to stop bleeding. 6. Suture the peritoneum of the esophageal hiatus: suture the peritoneal incision at the esophageal hiatus, and return the left lobe of the liver to the original site for gastric drainage or partial gastrectomy. complication 1. Perforation of the lower esophagus is a serious complication. Mainly due to damage when peeling off the lower end of the esophagus. The reported incidence in the literature is less than 0.5%. After the perforation occurs, if it can be found in the operation and repaired in time, the prognosis is good. Otherwise, it will cause severe underarm infection or mediastinal inflammation. Once this happens, surgery should be performed again. 2. Small curved ischemic necrosis and perforation. In the early stage of high-selective vagus nerve ablation, there have been some reports that it is related to the excessively wide, deep, and localized blood flow supply during the operation, and the incidence rate is less than 0.4%. Once the ischemic necrosis and perforation of the small curvature of the stomach occurs, the mortality rate is as high as 50%. Clinical manifestations of severe peritonitis. Surgical treatment should be performed immediately. This complication has been rare in recent years. In fact, local necrotic perforation of the stomach wall may be associated with surgical damage to the stomach wall. 3. Bleeding after surgery. The literature reports that the incidence of intra-abdominal hemorrhage after vagus nerve cutting is 0.3% to 0.8%. The main reason is that the intraoperative blood vessel ligation is not appropriate, and there are also iatrogenic injuries, such as rupture of the spleen due to traction, damage to the left lobe of the liver. Once it happens, it should be stopped again to stop bleeding.

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