The long-term results of vagotomy are closely related to the completeness of the vagotomy and to efficient drainage or resection of the antrum (see Chapter 22).

A careful evaluation of the adequacy and extent of the medical management is made. Proton pump inhibitors are effective in most patients and smoking cessation and Helicobacter Pylori eradication are important steps in medical management prior to operation. Obtaining fasting serum gastrin levels may be indicated. Persistent ulcer despite appropriate therapy may indicate the need for surgery. The laparoscopic approach is straightforward and should be considered.

General anesthesia with muscle relaxation is necessary. The insertion of an endotracheal tube provides smoother operating conditions for the surgeon and easy control of the airway for the anesthesiologist. An orogastric or nasogastric tube should be inserted to empty the stomach and allow palpation for the esophagus.

The patient is placed flat on the operating table, with the foot of the table lowered to permit the contents of the abdomen to gravitate toward the pelvis.

The skin is prepared in the usual manner.

A high midline incision is extended up over the xiphoid and down to the region of the umbilicus. In some patients the exposure is greatly enhanced by removal of a long xiphoid process. A thorough exploration of the abdomen is carried out, including visualization of the site of the ulcer. The location of the ulcer, especially if it is near the common duct, the extent of the inflammatory reaction, and the patient’s general condition should all be taken into consideration in evaluating the risk of gastric resection in comparison to a more conservative drainage procedure. The anatomy of the vagus nerve is shown in figure 1.