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With Laparotomy Vagotomy with Laparotomy ARTICLE BY RICHARD E. WILLS, MD, AND PEGGY E. GRUSENDORF, MS, RNP agotomy with chyme. The stomach lies under the tinuous above with the cardia and laparotomy is per- ribs and the costal cartilage that below with the pyloric antrum, formed in order to form the upper left quadrant. which connects with the pyloric reduce the amount The cardia (see Figure 1) is canal. The pylorus is apparent by a of gastric juices pro- located behind the 7th costal carti- small prepyloric vein in a shallow duced by the stom- lage, 2 to 3 cm left of midline. The groove, which is used as a landmark ach, which may cause intractable pylorus is 2.0 to 2.5 cm right of mid- during surgery. The stomach is duodenal or gastrojejunal ulcers. line in the trans-pyloric plane. The oblique and extends from the fundus The vagus nerves, which control pylorus is found in the area of L-1, downward, anteriorly and to the the amount of gastric acid present but the cardia is some distance ante- right. The lesser curvature is the in the stomach, are surgically tran- rior to T-11. These points and posi- right border, and the greater curva- sected, thereby interrupting the tions may vary considerably with ture is the left and inferior border of neural pathway. individual body build. Between the the stomach (see Figure 1). There are three methods used to cardia and pylorus of the stomach is The stomach is covered by peri- interrupt the vagus nerves. The the fundus, pyloric antrum, and the toneum except for an area posterior proximal gastric vagotomy divides pyloric canal (see Figure 1). In the to the cardiac orifice and one area the vagal nerves to the proximal upper left area of the cardia is the where the blood vessels course the stomach, but maintains the entire cardiac incisure (see Figure 1). This two curvatures. The two layers of stomach and the vagal nerves to area is between the left border of the peritoneum continue as the lesser the antrum. The selective esophagus and the stomach (see Fig- omentum at the lesser curvature and vagotomy transects the gastric ure 1). I at the greater curvature where the branches, preserving the innerva- The body of the stomach is con- I greate; omentum spreads out into tion of organs other than the stom- ach. The truncal vagotomy divides the vagal nerves at the distal Cardiac incisure esophagus and provides total vagal denervation of all structures below the diaphragm. This article will focus on the sur- gical procedure for the truncal vagotomy, including anatomic and physiologic considerations. Anatomy The stomach (Figures 1and 2) is a saclike area of the alimentary canal. Superiorly it is closed off from the esophagus (see Figure 1)by the cardiac sphincter and from the duodenum by the pyloric sphincter (see Figures 1and 2). The stomach functions by peristaltic activity that chums and homogenizes the swal- lowed foods, liquids, and saliva enzymes in addition to its own enzymes. The end product that is passed into the duodenum is called Figure 1. Longitudinal section of the stomach. THE SURGICAL TECHNOLOGIST APRIL 1993 the gastrophrenic, gastrosplenic, and gastrocolic ligaments. Histology Inside the esophagus and at the opening of the stomach, the epithe- Duodenal bulb, lium of the esophagus changes abruptly from stratified squamous cells to simple columnar cells. The mucosa of the stomach has numer- ous folds or ridges, known as rugae. The rugae vary in height and num- ber with the degree of distention of the organ. The entire surface of the Jejunum- gastric area is lined with depressions called gastric pits or foveolae. These depressions are shallow within the fundus while in the pyloric region they are much deeper. The epithe- lium that lines the inner surface of :@re 2. Barium swallow of the stomach and small intestine the stomach and gastric pits is made of columnar cells that function dif- jejunum. Gastrin is carried to the overlooked since it is more easily ferently from the cells of the gastric fundus, causing the parietal cells to separated from the esophagus. The glands. Overall, the characteristics of produce hydrochloric acid. posterior vagus also goes to the the stomach lining cells differentiate Hydrochloric acid then converts celiac ganglion (see Figure 3), where them from the lining cells of all other inactive pepsinogen from the chief parasympathetic fibers are distrib- parts of the digestive tract. cells into active pepsin, which acts uted to the body and the tail of the as a digestive protein. pancreas with communication to the Physiology entire small intestine and proximal The three functions of the stomach Neurophysiology colon. are to (1)mix food with gastric secre- Extrinsic innervation to the stomach The sympathetic nerves innervate tions, (2)store large quantities of comes from both sympathetic and via the greater splanchnic nerves food immediately after a meal, and parasympathetic branches of the and the celiac ganglion. The afferent (3)empty food from the stomach autonomic nervous system. Both branches from T-6 to T-10 conduct into the small intestine. carry afferent and efferent fibers. the visceral gastric pain impulses, A myriad of microscopic glands The parasympathetic innervation which are stimulated by muscle con- penetrate the mucous layer of the occurs via branches of the vagus traction, distention, and inflamma- stomach, which is lined with nerve that, when stimulated, cause tion. The efferent fibers inhibit gas- mucous-secreting cells. The glands increased gastric secretion of acid, tric secretion and motility. are categorized according to their gastrin, and pepsin, as well as There are two nerve plexus in the anatomic location within the stom- increased gastric moto; activity. The gastric wall: (1) Auerbach's, which ach. Cardiac glands are near the car- vagus nerve splits, forming two influence gastric motility, and(2) diac orifice and secrete mucous. main trunks at the level of the hiatus Meissner's, which provide innerva- Fundic glands of the stomach body (Figure 3). The anterior, or left, tion to the stomach and cause the are composed of three types of cells: vagus (see Figure 3) is found on the release of gastrin from the antrum. (1)chief cells that secrete mucous anterior wall of the.esophagus and Together they coordinate the motor and pepsinogen, (2)parietal cells divides into the hepatic and anterior and secretory activity of the gastric that secrete hydrochloric acid and gastric branches. The anterior mucosa. water, and (3) mucous neck cells that branch runs on to the front of the secrete only mucous. fundus and body of the stomach Use of Truncal Vagotomy The unstimulated stomach is while the hepatic branch runs into Bilateral resection of the vagus coated with visceral mucous mixed the lesser omentum of the liver, bile nerves in the region of the lower with an alkaline fluid. Argentaffin ducts, gallbladder, duodenum, esophagus reduces the amount of cells produce an intrinsic factor and pylorus, and right side of the pan- gastric juices produced by the stom- an antiemetic factor that allow vita- creas. ach and is one method for trea ting min BIZto be absorbed. The posterior, or right, vagus (see intractable duodenal or gastrojejunal The pyloric glands are near the Figure 3) divides into two branches: ulcers. pylorus and secrete pepsinogen and one at the posterior wall of the fun- Vagotomy eliminates cephalic mucous. A hormone called gastrin is dus at the body of the stomach and (vaga) stimulation of acid secretion secreted within the pyloric glands one at the posterior wall of the and reduces basal acid output by and the upper proximal part of the antrum. During surgery, it may be 80%to 90% and maximal (peak) acid THE SURGICAL TECHNOLOGIST APRIL 1993 output by 50nh to 60%. Truncal vago- secreted). just under the skin. This layer is usu- tomy also denervates the antral For controlling acid in managing ally incised with the cautery pencil pump mechanism, leading to chronic recurrent pancreatitis, the or knife. The surgeon clamps large delayed gastric emptying. With the vagotomy has been used in combi- bleeders in this layer with Kelly or motor paralysis, gastric retention nation with other procedures, Crile hemostats and ligates them that follows the vagotomy must be including the use of nasogastric with an absorbable suture, size 3-0, accompanied by a concomitant gas- feeding tubes, treatment with an H, or the surgeon may simply cauterize tric resection and/or drainage proce- blocker, and pancreatico- them. ' dure. This can be done with a jejunostomy. The incision is carried through to pyloroplasty or a gastroenterostomy the next layer, the fascia. At this placed in the pyloric antrum. There Surgical Procedure level the scrub person should have is a slight preference for pyloro- The first step is to perform a laparo- small Richardson or USA retractors plasty over gastroenterostomy in tomy. Routines that are followed available for the assistant. The sur- combination with vagotomy for the during every abdominal procedure geon incises the layer with a number treatment of peptic ulcers. are discussed here (adapted from 10 or 20 knife blade, from then on The use of truncal vagotomy to Schwartz S. Principles of Surgery). referred to as the deep knife. control the cephalic phase of secre- The patient is placed in the Throughout the procedure, the tech- tion (the phase mediated by efferent supine position, prepped, and nologist must exchange soiled lap activity of the vagus nerve) is pre- draped for the specific abdominal sponges for clean ones. ferred when it is desirable to retain incision. Once'draping is completed, The surgeon may lengthen the as much gastric capacity as possible the technologist moves the Mayo fascia1 incision with the cautery pen- because of the preoperative nutri- stand up to the field below the cil or may use curved Mayo scissors.
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