These procedures for chronic peptic ulcer are rarely undertaken, given the efficacy of modern medical therapy. Those who are adept at laparoscopic Nissen's fundoplication (see page 125) will have no difficulty in mobilizing the gastro-oesophageal junction and hiatal area to identify the anterior and posterior vagal trunks. The anterior vagus can readily be isolated from the anterior wall of the oesophagus with a diathermy hook and then divided using this same instrument. However, the posterior vagus nerve frequently contains a substantial blood vessel and it is more prudent to divide the nerve between clips. After truncal vagotomy a drainage procedure is mandatory and the simplest one to perform is the anterior gastro-jejunostomy described above (see page 130). It should be borne in mind that an anterior gastrojejunostomy defies conventional wisdom insofar as at open surgery it is conventional for this to be a posterior gastrojejunostomy.
The necessity for a gastric drainage procedure can be avoided by using one of the modifications of the highly selective procedure which appears not to disrupt the pyloro-antral emptying mechanism. The anterior nerve of Latarget is traced from its origin from the anterior vagus and all the branches which it sends to the lesser curvature of the stomach are divided down as far as the leash of blood vessels of the gastric incisura known as the 'crow's foot', keeping the main trunk on the nerve of Latarget intact. These branches run with the blood vessels supplying the lesser curvature of the stomach which must therefore be individually dissected free and divided between clips in such a manner as to denude the anterior portion of the lesser curve as far as the lower 4 cm of the oesophagus, ensuring the integrity of the anterior vagus nerve and the nerve of Latarget. This process can be tedious and time consuming and a technique has been described whereby a linear stapler can be used to perform this part of the procedure, working from the 'crow's foot' up the lesser curve seriatim, but again, care must be taken to avoid damage to the main nerve of Latarget. If the vagotomy is to be completed as conventional highly selective vagotomy, the surgeon continues to work his way around the lesser curve of the stomach to divide those nerves (and blood vessels) in the middle and posterior leaves of the gastrohepatic omentum close to the stomach in order to avoid damage to the main trunk of the posterior nerve of Latarget.
An alternative and much less time consuming procedure to the conventional highly selective vagotomies is to perform a posterior truncal vagotomy and anterior leaf highly selective vagotomy. This appears to possess all the attributes of the conventional anterior, middle and posterior left highly selective vagotomy but is less tedious to perform. Some authors have modified this even further by suggesting that the anterior highly selective vagotomy may be substituted by an anterior gastric seromyotomy and claim equally effective results.
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