Stomach, Duodenum, and Esophagus

VAGUS NERVES (TRUNCAL AND HIGHLY SELECTIVE VAGOTOMY)

INCISION

Access to the chest and abdomen will facilitate this procedure (Figs. 3.2 and 5.1). If the chest has been dissected, remove the lungs and identify the thoracic esophagus.

OPERATIVE PROCEDURE

Through the thoracic exposure, identify the vagus nerve plexus on the thoracic esophagus. Notice that it is a true plexus but most commonly goes through the esophageal hiatus as an anterior and posterior dominant trunk. This pattern occurs in 88% of patients. Four vagal structures are identified in 7% and more than four vagal structures are identified in 5% of patients (Fig. 3.31A, B). In the author’s practice, it has been observed over many years and many patients that the anterior trunk often has more than one branch at the esophageal hiatus and the posterior trunk is a large dominant trunk at that level.

Perform a truncal vagotomy through an abdominal approach. Incise the peritoneal covering over the abdominal esophagus to expose the esophagus and surrounding attachments (Figs. 6.1 and 6.2). Mobilize the esophagus with blunt dissection and place a Penrose drain around it. Dissect the anterior surface of the esophagus and search for the anterior trunk of the vagus nerve and any branches. The vagus is identified by palpation of a firm, “bowstring” structure on the anterior surface of the esophagus. Using blunt finger dissection, elevate the esophagus away from the aorta. A similar bowstring identifies the posterior trunk by your index finger behind the esophagus. The “criminal nerve of Grassi” (Fig. 3.31A, B) is a branch to the proximal stomach, which splits off the posterior trunk in the chest and descends through the esophageal hiatus separate from the main posterior vagal trunk. Look for the criminal nerve. Secure the posterior and anterior trunks with a tonsil clamp. Transect and remove a 1-cm segment of each nerve, which in the OR is sent to pathology for confirmation. The two ends of each trunk are ligated with hemoclips.

Figure 6.1 Incision of the gastrohepatic ligament.

To perform a highly selective vagotomy (HSV), identify and preserve the “crow’s foot” of the anterior division of the nerve of Latarjet to the distal antrum and pylorus (Fig. 6.3) 6 cm proximal to the pylorus. Select the next proximal branch of the nerve of Latarjet to the stomach and transect it. In the OR, you will use metal clips. Continue the dissection proximally cutting these fine branches to the lesser curve of the stomach from the anterior nerve of Latarjet. Notice that small vessels often accompany these fine branches off the nerve of Latarjet. Continue the dissection proximally to the
esophageal hiatus and maintain the continuity of the anterior nerve of Latarjet and the anterior vagus nerve. Some surgeons recommend a limited takedown of the short gastric vessels to facilitate the 6-cm esophageal clearing step of HSV (Fig. 6.4).

Figure 6.2 View of the right and left crus of the esophageal hiatus.

Figure 6.3 Highly selective vagotomy and identification of “crow’s foot.”

Flip the stomach superiorly and look at the posterior surface of the stomach. This can also be performed from an anterior approach if the greater curve of the stomach has not yet been mobilized. Find the “crow’s foot” to be preserved. Select the next proximal branch
of the posterior nerve of Latarjet and transect it. In a similar fashion to the anterior side, continue the dissection staying very close to the lesser curve of the stomach, which will preserve the posterior nerve of Latarjet. Continue this dissection proximally transecting each branch from the nerve of Latarjet. When this is completed, flip the stomach down into its normal position. Now, clean off all small branches and areolar attachments from the anterior and posterior nerves of Latarjet to the lesser curve of the stomach.

Figure 6.4 Dimensions of HSV. View of HSV from anterior approach with clips applied.

Observe the lesser curve of the stomach and note that it has a 2- or 3-cm. bare area exposing the outer muscle fibers. Some surgeons recommend reperitonealizing this bare area to avoid the occasional necrosis caused by stripping the lesser curve of the stomach. Interrupted silk suture may be used to oppose the anterior and posterior borders of stomach serosa over the bare area created by HSV.

Vagus nerve trunks are apparent after HSV and can easily be divided to simulate truncal vagotomy.

CLINICAL HIGHLIGHTS

Transthoracic vagotomy is done in the distal thoracic esophagus near the esophageal hiatus. This procedure is utilized to salvage prior truncal vagotomy that was clinically incomplete (see Chapter 3).
The “criminal nerve of Grassi” is simply the most superior branch of the posterior vagus. This particular branch divides from the right vagus in the chest and descends separately from the posterior trunk into the abdomen. Be aware that small branches of the vagus may descend through the esophageal hiatus separate from the main trunks. It is particularly important to remember to transect the criminal nerve during vagotomy to treat peptic ulcer disease (Fig. 3.31A, B).
Highly selective vagotomy, superselective vagotomy, proximal gastric vagotomy, and parietal cell vagotomy all refer to the same operation.
Damage to the crow’s foot during HSV may inhibit relaxation of the pylorus.
Nerves of Latarjet can have highly variable structure but will always have gastric branches that are the target of HSV.
Truncal vagotomy is always accompanied by a drainage procedure such as pyloroplasty. Otherwise, 40% of patients with truncal vagotomy will have pyloric spasm and will require reoperation for gastric drainage.
Remember that truncal vagotomy may involve more than a single vagal nerve trunk in either the anterior or posterior position.
Although transection of the nerve in truncal vagotomy should be sufficient, many surgeons remove a 1-cm segment of each nerve and send it to pathology for confirmation.
Clips placed on the vagal ends will show on future chest x-rays to show a vagotomy was performed.
To ensure complete transection of the vagal trunks, it is recommended to clear the distal esophagus superiorly for 5-6 cm of all investing tissues.

ESOPHAGEAL HIATUS (NISSEN FUNDOPLICATION)

INCISION

Access to the chest and abdomen will facilitate this procedure (Figs. 3.2 and 5.1). Reflect the anterior chest wall superiorly and the anterior abdominal wall inferiorly.

OPERATIVE PROCEDURE

This portion will require two participant surgeons. The assistant surgeon will vigorously elevate under the liver displacing the left lateral lobe superiorly. The assistant surgeon may choose to stand at the head of the table or on the cadaver’s left side. The primary surgeon should stand on the right side of the cadaver. Dissection commences in the gastrohepatic ligament (Fig. 6.1). This ligament is typically a thin, translucent veil of tissue. However, be aware that aberrant left hepatic vessels (replaced or accessory) may be identified in this location (Fig. 6.5). A “replaced” vessel replaces a major named vessel. “Accessory” means the normal vessel is present in addition to the accessory vessel.

Figure 6.5 Aberrant hepatic vessels in the gastrohepatic ligament.

Continue dissection to the right crus of the esophageal hiatus. Clear the edge of the right crus and separate the wall of the esophagus from it. Divide the peritoneum over the esophagus anteriorly and find the areolar plane between the esophagus and the right crus (Fig. 6.2). Once this areolar plane is identified, continue dissection of the right crus posteriorly. Next, develop this areolar plane anteriorly and separate the esophagus also from the left crus of the esophageal hiatus by dividing the gastrophrenic ligament (Fig. 6.6).

Continue dissection of the left crus and the esophageal hiatus posteriorly. Clear all peritoneal attachments from this edge. Further develop the plane between the esophageal hiatus and the esophagus to mobilize the distal 4 cm. of the esophagus into the abdomen. Develop the plane between the esophagus and the diaphragm posteriorly with the right index finger coming from the left crus, behind the esophagus. During this dissection, identify a tight band of tissue, which causes a “bowstring” effect. The bowstring is the posterior vagus nerve. Include the posterior vagus with the esophagus as the esophagus is mobilized.

Examine the entire esophageal hiatus of the diaphragm and note that the right and left crus of the esophageal hiatus arise from the right crus of the diaphragm (Fig. 6.7). The gastrohepatic and gastrophrenic ligaments (Fig. 6.1), posterior esophageal areolar attachments, and peritoneal attachments of the cardia of the stomach must all now be mobilized and free. Place the right index finger behind
the esophagus through the space now created. Repair the hiatal hernia posteriorly by suturing the right and left crus together (Fig. 6.8). The cardia of the stomach can be alternately pushed and pulled through this created space and a Nissen fundoplication can be performed (Fig. 6.9). Due to the stiff nature of cadaveric tissue, the fundoplication wrap may need to be formed and held with two hands or two Babcock clamps prior to suture (Fig. 6.10). Using 2-0 silk, place deep submucosal sutures beginning on the left side of the stomach, then picking up anterior esophageal muscle fibers and finally ending with a good deep submucosal bite of the stomach on the right side. Place three of these sutures causing a 3- to 3.5-cm wrap (Fig. 6.11). At this point, note how good mobilization of the greater curvature of the stomach aids in effective
fundoplication. The author places the superior fundoplication stitch to incorporate the right crus. This is done to prevent rupture of the fundoplication into the chest through the repaired hiatus (Fig. 6.11).

Figure 6.6 Mobilization of the stomach.

Figure 6.7 Right and left crus of the esophageal hiatus originating from the right crus of the diaphragm.

Figure 6.8 Repair of esophageal hiatus for hiatal hernia.

Figure 6.9 Traction of cardia for Nissen fundoplication.

Figure 6.10 Formation of gastric walls for Nissen fundoplication.

Figure 6.11 Sutures for Nissen fundoplication.

CLINICAL HIGHLIGHTS

The gastrohepatic ligament will contain aberrant hepatic arteries in ˜11% of patients (Fig. 6.5). Preservation should be attempted. The vessels can be divided if necessary without causing harmful ischemia to the left lobe of the liver.
Right and left crus of the esophageal hiatus both arise from the right crus of the diaphragm in most cases (Fig. 6.7).
Right and left pleural reflections are close to the mediastinal dissection of the esophagus and may be torn during surgery. After Nissen fundoplication, whether open or laparoscopic, remember to obtain a postop chest x-ray to rule out pneumothorax.
With the right index finger placed posterior to the esophagus to create the space for a Nissen wrap, note the transverse angle of the finger. Now, think about port placement for a laparoscopic Nissen. It is easy to see that the right medial subcostal port needs to be very close to the rib margin in order to have a Babcock clamp follow this transverse trajectory (Fig. 6.9).
Remember during Nissen fundoplication, use esophageal dilators of 50-60 French with or without the presence of a nasogastric tube when suturing the wrap to avoid postoperative dysphagia.
Esophageal perforation during Nissen fundoplication is most commonly associated with severe esophagitis. Preoperative endoscopy should be performed by the surgeon for anatomical considerations and for evaluation of the status of the esophagus. Esophagitis must be medically controlled preoperatively to avoid perforation at surgery.

Figure 6.12 A, B: Muscular layers of the stomach emphasizing the circular lower esophageal sphincter, angle of His, and collar of Helvetius.
The Nissen fundoplication re-establishes the angle of His. An acute angle of His must be established for the collar of Helvetius (oblique muscle band) to act as an active part of the lower esophageal sphincter in concert with the inner circular muscle layer of the esophagus. Place an instrument in the newly established angle of His after your Nissen to demonstrate (Fig. 6.12A, B).

GREATER CURVATURE OF THE STOMACH AND SHORT GASTRIC VESSELS (MOBILIZATION FOR ESOPHAGECTOMY OR FUNDOPLICATION)

INCISION

Access to the chest and abdomen will facilitate this procedure (Figs. 3.2 and 5.1). Reflect the abdominal wall inferiorly and the anterior chest wall superiorly. Identify the stomach. Identify the right gastroepiploic artery on the greater curvature of the stomach and be certain to preserve it.

OPERATIVE PROCEDURE

Elevate the stomach and identify the right gastroepiploic artery. Trace this artery back under the pylorus as it then branches off the gastroduodenal artery. Note the close proximate relationship between the gastroduodenal artery and the posterior duodenal bulb (Fig. 6.13). A posterior duodenal ulcer, which erodes through the wall of the duodenum, may erode into the gastroduodenal artery. If the penetrating ulcer causes profuse hemorrhage, it will require emergent surgery.

Figure 6.13 Exposure of gastroduodenal, right gastroepiploic, and superior pancreaticoduodenal arteries to demonstrate their locations for hemorrhage due to penetrating peptic ulcer.

Enter the lesser sac. See how you gain access to the posterior stomach, pancreas, or pancreatic pathology such as pancreatic pseudocyst. Note that the transverse mesocolon may be at risk (Fig. 6.14). Inflammatory or malignant adhesions may cause the greater omentum and the transverse mesocolon to fuse. This may put the blood supply to the transverse mesocolon at risk when entering the lesser sac. So begin by entering the lesser sac laterally and mobilize the greater curve medially (Fig. 6.14).

Trace the right gastroepiploic artery distally in its course along the greater curvature of the stomach (Fig. 5.2). This artery must be preserved during transhiatal esophagectomy when the stomach is used as the replacement conduit. The majority of the blood supply to the stomach is supplied by the right gastroepiploic artery after mobilization of the stomach. Free the remainder of the greater curvature of the stomach from the greater omentum (Fig. 6.6). Moving to the left, attempt to identify the left gastroepiploic artery. This artery arises from the splenic artery and has a tortuous, variable course along the left gastric border (Fig. 5.2). Continue dissection along the left greater curvature. Dissection in this area is through the gastrosplenic ligament. This may be a single sheet of tissue or two sheets of tissue (Fig. 6.15).

Continue sharp transection of the gastrosplenic ligament close to the stomach superiorly. Note the short gastric vessels encountered, which are transected and ligated individually. Carry this sharp dissection up to the diaphragm through the gastrophrenic ligament (Fig. 6.6). This will mobilize the entire greater curvature and cardia of the stomach. Elevate the stomach and look into the lesser sac. Identify the anterior wall of the pancreas. Inferior to the pancreas, identify the transverse mesocolon.

CLINICAL HIGHLIGHTS

The gastrosplenic ligament may have one or two welldefined folds. During mobilization of the greater curvature of the stomach, if present, the presplenic fold may be confusing to the surgeon who is unaware of this anatomic variable (Fig. 6.15).
Remember that short gastric vessels may come off the superior-most aspect of the spleen. These socalled supreme short gastric vessels may be identified only at the uppermost portion of the cardia of the stomach in the gastrophrenic ligament. Be aware that inferior phrenic vessels may also be found in this area arising from branches of the celiac axis and traversing posterior to the esophagus (Fig. 5.2).

Figure 6.14 Entrance into the lesser sac; relationship of the greater omentum and transverse mesocolon.

Figure 6.15 Presplenic fold; gastrosplenic ligament with short gastric arteries.
In the operating room, the short gastric vessels can be divided and ligated individually or transected with a vessel coagulation device. Depending on the body habitus, the supreme short gastric vessels can be difficult to identify and control. Appropriate retraction, visualization, and careful dissection in this area are key to prevent massive hemorrhage.
When taking down the short gastrics, the surgeon must exercise care in retraction of the stomach, as overzealous retraction can lead to avulsion of the short gastrics from the splenic hilum, necessitating splenectomy.
Note that a pancreatic pseudocyst in the lesser sac will likely be adjacent to the posterior wall of the stomach. On the body, re-evaluate this relationship. The surgeon can now see why a posterior wall gastrocystostomy is a convenient and anatomically sensible method of pseudocyst drainage for lesser sac pseudocysts.
Remember the critical nature of the right gastroepiploic artery when performing transhiatal esophagectomy. The right gastroepiploic artery, the right gastric artery, and the extremely rich interconnected nature of the gastric submucosal plexus allow complete mobilization of a viable stomach for an esophageal replacement conduit.