Bilateral resection of segments of the vagus nerves in the region of the lower esophagus is a key component in treating intractable duodenal or gastrojejunal ulcers, refractory to antisecretory medicine or when intervening situation is not optimized. The motor paralysis and resultant gastric retention that may follow truncal vagotomy alone make it mandatory that a concomitant gastric resection or drainage procedure, such as pyloroplasty or an antrally placed gastroenterostomy, be performed. Gastrojejunal or stomal ulcers following a previous gastrectomy or gastrojejunostomy show a favorable response to vagotomy. The use of vagotomy to control the cephalic phase of secretion is preferred when it is desirable to retain as much gastric capacity as possible because of the preoperative nutritional status of the patient with duodenal ulcer. In those individuals below their ideal weight preoperatively, controlling the acid factor by vagotomy followed by pyloroplasty, posterior gastroenterostomy, or hemigastrectomy should be seriously considered. In many patients laparoscopy provides excellent exposure of the vagal trunks and mobilization of the distal esophagus can be straightforward. In patients with scarring or previous operation consideration could be given to a transthoracic thoracoscopic approach via the left chest to the GE junction. There are two vagal trunks—the anterior or left vagus nerve, which lies along the anterior wall of the esophagus, and the posterior or right vagus nerve, which is sometimes overlooked since it is more easily separated from the esophagus. The vagus nerves may be divided 5 to 7 cm above the esophageal junction (truncal vagotomy), divided below the celiac and hepatic branches (selective vagotomy), or divided so that only the branches to the upper two-thirds of the stomach are interrupted, while the nerves of Latarjet, innervating the antrum or lower one-third, as well as the celiac and hepatic branches, are retained (proximal gastric vagotomy).

A good exposure of the lower end of the esophagus is essential and sometimes requires removal of the xiphoid as well as mobilization of the left lobe of the liver. The vagal nerves should be identified and divided as far from the esophagogastric junction as possible (figure 1). Sections of these trunks should be sent to the pathologist for microscopic evidence that at least two vagus nerves have been divided. Whether silver clips or ligatures are applied to both ends of each nerve is the choice of the individual surgeon. It may be advisable to ligate the posterior nerve to control possible oozing that may take place in the mediastinum. The esophagus should be carefully inspected, and the area behind the esophagus, in particular, should be searched as the esophagus is retracted upward to make sure that the posterior vagus nerve is not overlooked. In most instances, the cephalic phase of secretion will not be controlled if vagotomy has been incomplete. Some prefer to combine the vagotomy with a hemigastrectomy in order to control the gastric phase of secretion as well as the cephalic phase. Drainage of the antrum is essential by pyloroplasty, gastroenterostomy, or gastroduodenostomy (see Chapters 20–21). The increased incidence of recurrent ulceration following vagotomy and antral drainage by pyloroplasty or gastroenterostomy must be weighed against a somewhat higher mortality following vagotomy and hemigastrectomy.