The goal of operative therapy is to reduce gastric acid secretion. This is accomplished by removing the vagal stimulation via vagotomy, removing gastrin-drive secretion by an antrectomy, or both.
Vagotomy without drainage procedure results in delayed gastric emptying due to loss of receptive relaxation. Truncal vagotomy and selective vagotomy require a drainage procedure to prevent delayed gastric emptying, whereas a highly selective vagotomy does not require a drainage procedure as it preserves vagal innervation to the antrum and pylorus.
Antrectomy is more commonly performed for gastric ulcers and requires gastrointestinal reconstruction such as Billroth I, Billroth II, or Roux-en-Y. Type II and III gastric ulcers require a vagotomy as they are associated with increased gastric acid.
Malignancy is more of a concern in gastric ulcers (as opposed to duodenal ulcers). Thus, resection is commonly indicated.
Exposure of the anterior and posterior vagus nerves is necessary when performing a vagotomy. This can be accomplished by elevating the left lobe of the liver with a liver retractor and incising the peritoneal reflection (the phrenoesophageal ligament) over the distal esophagus.
Truncal vagotomy is performed by dividing the left and right vagus nerves above the GE junction. It is the most common operation performed for duodenal ulcer disease.
Selective vagotomy divides the main right and left vagus nerves distal to the celiac and hepatic branches.
Highly selective vagotomy divides only the vagus nerves supplying the acid-producing portion of the stomach within the corpus and fundus.
The criminal nerve of Grassi from the posterior trunk must be divided in a vagotomy because it will predispose to recurrent ulcer disease if left intact.
Drainage procedures include Heineke-Mikulicz pyloroplasty, Finney pyloroplasty, and Jaboulay gastroduodenostomy.
In routine cases, the Heineke-Mikulicz pyloroplasty is recommended.
In cases where the stomach lays in longitudinal axis, where ulcers are present in the second portion of the duodenum, or with chronic inflammation displacing the pylorus, a Finney pyloroplasty is recommended.
In severe scarring or fibrosis, the Jaboulay gastroduodenostomy is an option.
A Kocher maneuver may be necessary for pyloroplasty procedures to mobilize the duodenum.
Educational aid only. Verify every dose, indication, and guideline against current institutional protocol. This is not a substitute for clinical judgment.
