Vagotomy of the stomach: stem, selective and selective proximal. Complications after surgery

Vagotomy is a surgical operation in the stomach area, which involves cutting individual branches or the entire vagus nerve. The presented type of intervention is used for therapy against gastric and duodenal ulcers. There are several types of vagotomy, each of which has its own functions.

The essence of the operation

So, as noted earlier, vagotomy is a type of surgical operation that is used to treat certain conditions and diseases of the stomach. First of all, experts pay attention to the possibility of excluding gastric and duodenal ulcers. Besides, we're talking about about getting rid of reflux esophagitis and other problematic conditions of the esophagus. Vagotomy, as an operation, involves the intersection of the vagus nerve or several of its branches, which stimulate the secretion of hydrochloric acid in the stomach.

The scale of the intervention is determined individually by a specialist each time and depends on certain characteristics of the patient’s condition. In particular, the determining characteristics may be age, the presence of inflammatory and other diseases of the stomach. In some cases, vagotomy is the only way get rid of certain diseases.

The main goal of vagotomy should be considered to reduce the production of acid components in the stomach. In addition, it is the presented intervention that ensures rapid and rarely recurrent healing of gastric ulcers and those related to the duodenum.

Also, as experts note, it is vagotomy that makes it possible to reduce the effect of acid on the mucous membrane of the esophagus due to a decrease in the degree of acidity of the contents in the stomach area.

Considering all this, there is no doubt why the presented type of surgical intervention is one of the most popular today. It is also necessary to take into account the fact that there are certain types of surgery that are used depending on the diagnosis and the existing stomach disease. The classification with which vagotomy is associated will be discussed in more detail below.

Main types of vagotomy

Types of surgery are classified depending on the intervention algorithm; according to this, vagotomy can be of three types: trunk, selective and selective proximal. Stem surgery involves cutting the trunks of the vagus nerve. This is carried out directly above the diaphragm area up to the branching of the trunks. In this case, truncal vagotomy provokes denervation of all organs of the peritoneum, relieving inflammation and other negative symptoms of the stomach.

This type of surgery has a significant drawback. It lies in the fact that the intersection of the celiac and hepatic branches deprives some internal organs(these include the pancreas, liver, intestines) specific innervation. This, in turn, affects the formation of a specific syndrome, namely post-vagotomy consequences that destabilize the activity of the stomach.

The next type of operation is selective vagotomy, which crosses absolutely all gastric branches associated with the vagus nerve. Experts pay attention to following features this type of intervention:

1. preservation of the branches that go to the liver and solar plexus area;
2. the operation is performed exclusively on the area below the esophageal diaphragm;
3. is used, compared to other methods, quite often, ensuring the longest possible preservation and functioning of the areas of the stomach.

It is the selective type of vagotomy that makes it possible to preserve the normal functioning of the vagal nerve. Next, I would like to draw attention to the third type of surgical intervention, namely selective proximal vagotomy.

As part of the intervention, only those branches of the vagus nerve that pass to the upper compartments of the stomach are crossed.

This option is currently assessed by experts as one of the most preferable. This is explained by the fact that it is with its help that it is possible to maintain not only the maximum shape, but also the functions associated with the stomach. It is necessary to pay attention to the fact that the operation can be carried out in two ways: mechanical dissection with special instruments and medical-thermal intersection.

In addition, vagotomy sometimes accompanies other types of surgical intervention. This happens, in the vast majority of cases, during the treatment of duodenal ulcer. Traditionally, the operation is accompanied by drainage of the stomach area or is accompanied by a fundoplication. Speaking about all the features of vagotomy, one cannot help but pay attention to what complications it may be associated with.

Complications after surgery

In a certain number of patients, despite vagotomy, the production of acid and pepsin is restored after a certain period of time. The consequence of this is that the peptic ulcer disease recurs. In general, at least 4% of those who undergo surgery are identified with severe motor and evacuation disorders that are associated with the functioning of the stomach. In addition, this is what affects the development of severe diarrhea.

Such processes can be so aggressive that additional surgical intervention is sometimes required. In a certain number of patients, after performing one of the types of surgery, namely the stem type, two to three years later, calculi (stones) are identified in the area of ​​the gallbladder.

Complications that develop after vagotomy are largely determined by the operation algorithm itself.

As noted earlier, when the vagal nerve is dissected, parasympathetic innervation is disrupted. This is not just due to the production of acid in the stomach area, but also affects the rest of its parts. In addition, other organs may be involved abdominal cavity.

U significant amount In patients who underwent vagotomy, the so-called “post-vagotomy syndrome” was formed. It is associated with developing disorders of the evacuation function in relation to the contents of the stomach. Subsequently, this provokes quite severe consequences, in some cases can even lead to death.

Thus, gastric vagotomy is the most important operation, allowing you to save normal work stomach and get rid of certain pathological changes. At the same time, the intervention can provoke complications, and in some cases there is a relapse of the condition. In this regard, it is recommended to follow all the specialist’s recommendations and consult a doctor in a timely manner.

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1.Can cancer be prevented?
The occurrence of a disease such as cancer depends on many factors. No person can ensure complete safety for himself. But significantly reduce the chances of occurrence malignant tumor everyone can.

2.How does smoking affect the development of cancer?
Absolutely, categorically forbid yourself from smoking. Everyone is already tired of this truth. But quitting smoking reduces the risk of developing all types of cancer. Smoking is associated with 30% of deaths from cancer. In Russia, lung tumors kill more people than tumors of all other organs.
Eliminating tobacco from your life - best prevention. Even if you smoke not a pack a day, but only half a day, the risk of lung cancer is already reduced by 27%, as the American Medical Association found.

3.Does it affect excess weight on the development of cancer?
Look at the scales more often! Extra pounds will affect more than just your waist. The American Institute for Cancer Research has found that obesity promotes the development of tumors of the esophagus, kidneys and gallbladder. The fact is that adipose tissue serves not only to preserve energy reserves, it also has a secretory function: fat produces proteins that affect the development of a chronic inflammatory process in the body. And oncological diseases appear against the background of inflammation. In Russia, WHO associates 26% of all cancer cases with obesity.

4.Do exercise help reduce the risk of cancer?
Spend at least half an hour a week training. Sport is on the same level as proper nutrition when it comes to cancer prevention. In the United States, a third of all deaths are attributed to the fact that patients did not follow any diet or pay attention to physical exercise. The American Cancer Society recommends exercising 150 minutes a week at a moderate pace or half as much but at a vigorous pace. However, a study published in the journal Nutrition and Cancer in 2010 shows that even 30 minutes can reduce the risk of breast cancer (which affects one in eight women worldwide) by 35%.

5.How does alcohol affect cancer cells?
Less alcohol! Alcohol has been blamed for causing tumors of the mouth, larynx, liver, rectum and mammary glands. Ethanol decomposes in the body to acetaldehyde, which then, under the action of enzymes, turns into acetic acid. Acetaldehyde is a strong carcinogen. Alcohol is especially harmful for women, as it stimulates the production of estrogens - hormones that affect the growth of breast tissue. Excess estrogen leads to the formation of breast tumors, which means that every extra sip of alcohol increases the risk of getting sick.

6.Which cabbage helps fight cancer?
Love broccoli. Vegetables are not only included in healthy diet, they also help fight cancer. This is why recommendations for healthy eating contain the rule: half daily ration should be vegetables and fruits. Particularly useful are cruciferous vegetables, which contain glucosinolates - substances that, when processed, acquire anti-cancer properties. These vegetables include cabbage: regular cabbage, Brussels sprouts and broccoli.

7. Red meat affects which organ cancer?
The more vegetables you eat, the less red meat you put on your plate. Research has confirmed that people who eat more than 500g of red meat per week have a higher risk of developing colorectal cancer.

8.Which of the proposed remedies protect against skin cancer?
Stock up on sunscreen! Women aged 18–36 are especially susceptible to melanoma, the most dangerous form of skin cancer. In Russia, in just 10 years, the incidence of melanoma has increased by 26%, world statistics show an even greater increase. Both tanning equipment and Sun rays. The danger can be minimized with a simple tube of sunscreen. A 2010 study in the Journal of Clinical Oncology confirmed that people who regularly apply a special cream have half the incidence of melanoma than those who neglect such cosmetics.
You need to choose a cream with a protection factor of SPF 15, apply it even in winter and even in cloudy weather (the procedure should turn into the same habit as brushing your teeth), and also not expose it to the sun's rays from 10 a.m. to 4 p.m.

9. Do you think stress affects the development of cancer?
Stress itself does not cause cancer, but it weakens the entire body and creates conditions for the development of this disease. Research has shown that constant worry alters the activity of immune cells responsible for triggering the fight-and-flight mechanism. As a result, a large amount of cortisol, monocytes and neutrophils constantly circulate in the blood, which are responsible for inflammatory processes. And as already mentioned, chronic inflammatory processes can lead to the formation of cancer cells.

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Selective proximal vagotomy- surgery, one of the options for operations vagotomy, which consists in the intersection of the vagus nerve (vagus) or its individual branches, stimulating the secretion of hydrochloric acid in the stomach. Selective proximal vagotomy, like other vagotomy options, is used to treat gastric and duodenal ulcers, reflux esophagitis and other acid-related diseases. Selective proximal vagotomy code (without drainage) A16.16.018.002.

Selective proximal vagotomy, compared with other vagotomy options, produces a minimal number of complications. In modern conditions, it is often performed in combination with other operations on the gastrointestinal tract, including minimally invasive access, laparoscopically, as well as medical-thermal methods.

The difference between selective proximal vagotomy and other types of vagotomies

An important disadvantage of the classic version of vagotomy is that the cut vagal nerves innervate not only the acid-producing fields of the stomach, but also its other areas and other organs digestive system. Therefore, after their denervation, the so-called post-vagotomy syndrome often occurs, consisting of a disorder of motility of the stomach and other organs, often manifested in the form of severe diarrhea, as well as others serious complications.

In order to reduce the effect of denervation of areas of the stomach that do not contain acid-secreting parietal cells, the operation of selective proximal vagotomy was developed, in which parasympathetic denervation is carried out only in acid-producing zones - the fundus of the stomach and the body of the stomach. It is important to preserve the innervation of the antrum of the stomach, so that the mechanism for regulating acid neutralization is not disrupted.

Limitations of selective proximal vagotomy

Selective proximal vagotomy finds limited use in the surgical treatment of “complex” ulcers of the duodenal bulb, since such patients rarely have a combination of all necessary conditions: absence of pronounced hypersecretory activity of the stomach (up to 30 mmol/l); the presence of unchanged mucous membrane of the antrum and fundus of the stomach; absence of sub- and decompensated forms of duodenostasis. Selective proximal vagotomy must be supplemented by removal of the ulcer and duodenoplasty, if there is no organic failure of the pyloric sphincter, or pyloroplasty, if there is an organic or functional failure of the pyloric sphincter (V.V. Sakharov).

Laparoscopic selective proximal vagotomy using the skeletonization method is a lengthy, technically complex, expensive surgical intervention and can be successfully performed in specialized medical institutions(O.V. Oorzhak).

Control of the completeness of vagotomy

Since the purpose of the operation for selective proximal vagotomy is to suppress the vagal fibers going to the acid-producing fields of the stomach and not to cross the rest, control of the completeness of the vagotomy is the most important component of the operation. Teams of doctors and engineers under the leadership of corresponding member. RAMS Yu.M. Pantsyreva and acad. RAS A.N. Devyatkov developed equipment and a method for monitoring the completeness of vagotomy using intraoperative intragastric pH-metry. For intraoperative pH-metry, a special pH probe with a channel for aspiration of gastric contents and an intraoperative acidogastrometer are used. Drugs that affect gastric secretion are excluded from preoperative preparation. After laparotomy and revision of the abdominal cavity, pentagastrin is administered intravenously at a dose of 0.006 mg per kg of patient weight or histamine at a dose of 0.024 mg/kg. Against the background of stimulation of secretion, the initial pH values ​​​​in the stomach are measured. When determining hypo- and anacidity, the test is considered uninformative and is not performed. 3-45 minutes after the administration of pentagastrin (histamine), stimulation of secretion continues throughout the entire operation. During vagotomy and after its completion, careful aspiration of gastric contents through a probe is carried out. After performing selective proximal vagotomy, measurement of the acidity of the mucous membrane is achieved by the surgeon by pressing an antimony electrode against the wall of the stomach without excessive pressure along four main lines - the lesser and greater curvature, the anterior and back wall. In the presence of secreting fields, additional intersection of intact nerve fibers and repeated control of vagotomy are performed. Vagotomy is considered complete when the pH across the entire surface of the gastric mucosa increases to 5 or more (Yu.M. Pantsyrev, S.A. Chernyakevmch, I.V. Babkova, 1999).
		Intraoperative pH probe with cheek calomel reference electrode and channel for aspiration of gastric contents

Professional medical publications addressing issues of selective proximal vagotomy

• Stanulis A.I., Kuzeev R.E., Goldberg A.P., Naumov P.V., Kuzina O.A. A new method of selective proximal vagotomy in the treatment of duodenal ulcer // Healthcare and medical technology. – 2004. – No. 4. – p. 22–23.

VAGOTOMY(Latin, vagus + Greek, tome incision, dissection) - the operation of crossing the vagus trunks or their branches. It is one of the methods of surgical treatment peptic ulcer; It is usually used in combination with gastric surgery.

The theoretical premises of V. were experimental work the school of I. P. Pavlov (1889) and the work of Cannon (N. V. Cannon, 1906), which proved the role of the vagus nerves in the regulation of the secretory and motor functions of the stomach.

V. suppresses gastric secretion in response to imaginary feeding, and its emptying in the first period after surgery is much slower. It was also noted that the intersection of the vagus trunks at the level of the diaphragm does not lead to any serious violations breathing and cardiac activity.

The first attempt to use V. for the treatment of stomach ulcers in the clinic was made by Exner and Schwarzmann (A. Exner, E. Schwarzmann, 1912).

In the 20-30s of the 20th century. V. was not popular among surgeons, however, the issues of surgical technique and its results were periodically discussed in the literature, but on a relatively small number of observations. Interest in this operation increased significantly after the works of Dragstedt (L. R. Dragstedt, 1943, 1945, 1950, 1952) et al., who presented quite convincing pathophysiological justifications for V. and a large clinical material. Experimental studies have shown that the intersection of the vagus trunks leads to a significant decrease in the production of hydrochloric acid by the stomach, and also prevents the formation of experimental peptic ulcers in animals. Clinical researches identified a sharp decline after V. 12-hour night salt secretion (so-called basal secretion) in patients with ulcers. The gradual increase in acid production, sometimes observed after this operation, is directly related to the disruption of evacuation from the vagotomized stomach, resulting in secondary stimulation of the hormonal phase of secretion. As a result, severe dyspeptic symptoms, lack of healing, or even relapse of the ulcer are observed. It is for this reason that most authors consider V. alone without accompanying drainage (facilitating evacuation) interventions on the stomach to be an operation that does not provide a reliable effect and, therefore, is unacceptable for the treatment of peptic ulcer.

V. in combination with stomach drainage operations (pyloroplasty, gastroduodeno-, gastrojejunostomy) has been quite popular since the 60s. wide use as an operation that significantly reduces gastric secretion and creates conditions for healing the ulcer with minimal surgical risk.

V. and economical gastrectomy (hemigastrectomy, anthrumectomy) are used as one of the methods of surgical treatment of complicated duodenal ulcers. With this operation, in most cases, not only the pathological focus is eliminated, but also conditions are created for reliable suppression of gastric secretion both in the first (nervoreflex) and in the second (humoral) phase.

In the practice of surgical treatment of peptic ulcers, each mentioned operation has its own indications; the right method can provide maximum effect in relation to healing the ulcer with minimal undesirable consequences of the surgical intervention itself.

There are fundamentally various options V. depending on the anatomical details of the operation and the degree of denervation of the abdominal organs achieved. With trunk (truncular) V., the vagus trunks are usually crossed at the level of the diaphragm, before they branch, which leads to vagal denervation not only of the stomach, but also of other organs of the digestive system. Selective (selective) V. consists of crossing all the gastric branches of the vagus trunks, while the functionally important branches going to the liver and solar plexus remain intact.

Preservation of the visceral branches of the vagus nerve leading to the intestines, pancreas and biliary tract should theoretically prevent the development of such undesirable consequences complete V., such as diarrhea, dysfunction of the pancreas, gall bladder and biliary tract. Finally, with the so-called proximal gastric V. the branches of the vagus nerves are selectively intersected only to the upper parts of the stomach. This operation achieves partial denervation of the stomach only in the area of ​​distribution of acid-producing (parietal) cells of the mucous membrane, and therefore some authors call it “selective vagotomy of the parietal cell mass” [Amdrup and Griffith (V.M. Amdrup, S.A. Griffith) 1969]. Preservation of vagal innervation of the antrum of the stomach is ensured, according to Holle and Hart (F. Holle, N. Hart., 1967), Miller (B. Miller) et al. (1971), not only the normal motor function of the latter, but also one of the important inhibitory mechanisms of gastric secretion.

Indications

Indications for V.'s use, according to most surgeons, are complicated or stubbornly intractable conservative treatment duodenal ulcers, as well as postoperative peptic ulcers. As already emphasized, V., as a rule, should be combined with surgical intervention on the stomach itself (drainage operations or economical resection). At the same time, in cases of complicated duodenal ulcers (stenosis, penetration), economical resection should be performed; in cases of uncomplicated ulcers, various types pyloroplasty.

For gastric ulcers, V., as a rule, is not indicated; in these cases, gastric resection is used in various modifications (see Billroth operations).

Domestic and foreign surgeons are studying the possibilities of using V. in emergency surgery - for perforated and bleeding duodenal ulcers. Excision of a perforated or bleeding ulcer followed by pyloroplasty and V. are pathogenetically based surgical interventions, which are accompanied by a significantly lower operational risk than gastric resection. The last circumstance is the most important, especially in elderly patients and in the presence of concomitant diseases.

Operation technique

Preparation for the operation does not differ in any particularities and consists of elements that ensure the implementation of surgical intervention on the gastrointestinal tract. tract. Pain relief - general.

Transperitoneal vagotomy. The most convenient access to the subphrenic space is provided by the upper midline incision. The esophageal hiatus of the diaphragm is opened for viewing after retraction of the left lobe of the liver with a long retractor, which is facilitated by mobilization of the lobe by cutting the triangular ligament of the liver.

Truncal vagotomy. To perform stem V., it is necessary to isolate the nerve trunks just above the diaphragm, even before they divide into branches. After dissecting the sheet of peritoneum covering the diaphragm at the edge hiatus, the surgeon bluntly isolates the anterior and posterior trunks of the vagus nerves from the peri-esophageal tissue. Stretching the stomach makes it easier to find nerve trunks, which can often be multiple.

First, the anterior and then the posterior vagus trunk are crossed (Fig. 1), while in order to prevent regeneration, sections of the nerve 1.5-2 cm long are excised and both ends are tied with ligatures. The surgeon must be sure that all branches of the vagus nerves running at this level are crossed, since the effectiveness of the operation depends on the completeness of the V.

After careful hemostasis, the incision of the diaphragmatic peritoneum is sutured with several interrupted sutures.

Among the errors and dangers accompanying the operation of the trunk V., one should mention the incomplete intersection of additional nerve trunks or the main posterior vagus trunk, damage to the muscular and mucous membrane of the esophagus or the mediastinal pleura during manipulations in the mediastinum at the time of mobilization of the esophagus or when isolating the posterior vagus trunk.

Selective vagotomy, which provides isolated denervation of the stomach, is technically a more complex intervention. This circumstance, as well as insufficient clinical argumentation of the advantages of this method over stem V., still restrain surgeons from its widespread use.

To perform selective V., it is necessary to have a good knowledge of the anatomical details of the branching of the vagal trunks and their relationship with the vessels of the lesser curvature of the stomach; only under this condition is it possible to completely cross all gastric branches and preserve the hepatic branches of the anterior (left) vagus trunk, located in the lesser omentum, and the main branch of the posterior (right), going to the solar plexus.

Unlike the trunk V., all manipulations for the purpose of crossing the gastric branches of the vagus trunks are performed below the esophageal opening. First, the gastric branches of the anterior (left) vagus trunk are crossed. At the lesser curvature of the stomach, the descending branch of the left gastric artery is ligated and dissected. Along the intended line, from the lesser curvature to the left edge of the cardia, sections of the serous layer are dissected between the applied clamps, through which small vascular and nerve branches pass to the lesser curvature of the stomach (Fig. 2). All branches captured by clamps are carefully bandaged.

The posterior (right) vagus trunk is located behind the esophagus, entering the solar plexus with its main branch.

Intersection of the gastric branches of the posterior trunk becomes possible if good visibility of this area is ensured (Fig. 2). After completion of selective gastric V., the proximal part of the lesser curvature of the stomach, free from elements of the lesser omentum, is peritonized with gray-serous sutures.

Proximal selective vagotomy. During this operation, the nerve trunks running along the lesser curvature to the corner of the stomach are preserved along with the descending branches of the vessels (the so-called nerves of the lesser curvature of Latarget). The distal border of skeletonization of the lesser curvature of the stomach is marked at a distance of 4-6 cm from the pylorus, which usually corresponds to the border between the acid-producing and antral zones. It is also possible to determine this boundary absolutely accurately using special methods(intraoperative pH-metry, supravital staining).

First, they cross and carefully bandage everything small vessels and nerve branches extending from the anterior trunk to the lesser curvature (Fig. 3). This dissection of the tissues of the lesser omentum at the lesser curvature continues upward to the cardia and further to the fundus of the stomach at its junction with the esophagus (the angle of His).

After tensioning the lesser omentum, all nerve branches extending to the lesser curvature from the posterior trunk are crossed in the same way. Peritonization of the lesser curvature is performed.

Performing selective gastric V. in various modifications requires the surgeon to have a good knowledge of the anatomy of this area and adherence to the smallest details of the technique. All this ensures the completeness of the gastric cavity and eliminates unwanted complications.

The postoperative period in patients after gastric surgery using V. does not differ significantly from the postoperative period after conventional gastrectomy.

Complications of vagotomy

Immediate complications of vagotomy: delayed evacuation from the stomach, especially in those operated on for an ulcer complicated by stenosis of the outlet tract. Short-term drainage of the stomach using a nasogastric tube or through a temporarily placed gastrostomy tube usually prevents or quickly eliminates this complication.

Late complications or disorders caused by V. are reduced to a symptom complex, which is called “post-vagotomy syndrome” in the literature. This includes a fairly wide range of complaints, most often a feeling of fullness in the epigastrium, dysphagia (see), dumping syndrome (see Postgastroresection syndrome), diarrhea. According to a number of researchers [Cox (A. G. Sokh), 1968; Goligher (J. S. Goligher) et al., 1968], who specifically studied this issue, the incidence of post-vagotomy syndrome after V. in combination with drainage operations is 10%. There is no convincing clinical data in the literature on the dependence of the frequency of various disorders on the type of B.

The results of V.'s use in the surgical treatment of peptic ulcers should be considered satisfactory. So-called sparing operations on the stomach in combination with V. give lower mortality than subtotal resections. Mortality after drainage operations in combination with V., according to domestic and foreign surgeons, is 0.5-1.0%. Negative side These operations leave a relatively high percentage of ulcer recurrence (4-8%), according to J. A. Williams and Cox.

Vagotomy in experiment

Vagotomy in experiment- main or auxiliary operation to study the participation of the vagus nerve in the regulation of the functions of internal organs.

Dissection of the vagus nerve in the neck of warm-blooded animals (dog, cat, rabbit) is performed under superficial anesthesia. The approach to the nerve is carried out by making an incision (5 cm long) of the skin and subcutaneous tissue between the sternomastoid and sternohyoid muscles, in the caudal direction from the level hyoid bone. After spreading these muscles at the bottom of the wound, lateral to the trachea and 1 cm caudal to the larynx, the common carotid artery is felt, which, together with the neurovascular bundle, is bluntly separated from the surrounding tissue and raised with a ligature. The vago-sympathetic trunk welded to it is dissected from the vessels and taken for a ligature. The dense connective tissue membrane of the vagosympathetic trunk in dogs is opened with a longitudinal incision with a sharp eye scalpel and the vagus nerve, which is white in color with a pearlescent tint, is removed from it. Cervical fibers sympathetic nerve at the same time they remain in the thickness of the connective tissue membrane. In cats and rabbits, these nerves are easily divided by blunt force.

For acute experiments, e.g. for electrical stimulation of the central or peripheral end of the cervical vagus nerve, middle part the selected area of ​​the nerve is crossed between two ligatures.

In semi-chronic experiments, the nerve is cut 1-2 days after surgery, when the animal has fully recovered from anesthesia and injury. To do this, the vagus nerve is dissected as far as possible, after first cutting the sternohyoid muscle. A ligature is placed under the nerve, the nerve and the ligature are placed under the skin. Skin wound stitched up. On the day of the experiment, before the experiment, several skin sutures are removed and the nerve is pulled out by the ligature to quickly cut it at the right moment of the experiment. Multiple repeated “physiological transections” of the exposed vagus nerve are performed using a cold block.

For chronic experiments with repeated “physiological” V., the prepared vagus nerve is placed on the neck inside the cutaneous Filatov stalk. In this case, they use a modification of the Van Leersum operation, which is usually used to remove the general carotid artery.

Temporary “physiological” V. in such dogs is caused either by injection of a solution of novocaine (2% - 1 ml) into the thickness of the skin tube, or by cooling it along with the vagus nerve. A thin-walled rubber cuff, sewn into a nylon cover, is put on the isolated skin tube, through which water is passed under a pressure of 200 mm Hg. Art., cooled to G 3-7e or heated to 25-30e to quickly restore nerve conduction (I. Ya. Serdyuchenko, 1964).

Dissection of the vagus nerve for chronic experiments should be done extremely carefully, since severe irritation often leads to pulmonary edema or pneumonia and the death of the animal (A.V. Tonkikh, 1949). For the same reason, animals cannot tolerate simultaneous transection of both vagus nerves in the neck.

If for chronic experiments on dogs bilateral V. is necessary, for example, to study the functions of organs digestive tract, kidneys, etc., it is produced in two stages.

In the first operation, the right vagus nerve is cut at a site located distal to the origin of the pulmonary and cardiac branches and the recurrent nerve. An incision 8-10 cm long is made along the lower part of the lateral edge of the sternomastoid muscle and continues in the caudal direction to the pectoralis major muscle, but so as not to injure the subcutaneously located external jugular vein. The muscles of the neck and chest are dissected from the surrounding tissues and pulled in the medial direction. At the bottom of the wound, a neurovascular bundle is found, consisting of the common carotid artery and the vagosympathetic trunk. The nerve is taken with a ligature and, moving upward and to the side pectoral muscle, slightly open the entrance to the chest cavity. Using long hooks in good lighting, widen the wound and dissect the nerve until subclavian artery. Here, cardiopulmonary branches depart from the vago-sympathetic trunk, forming a subclavian loop, and the lower laryngeal (recurrent) nerve begins. Using a Deschamps needle, a ligature is placed under the trunk of the vagus nerve, located caudal to the origin of the subclavian loop. Continuing the blunt dissection of the trunk of the vagus nerve, isolate it at the greatest possible distance, cut out a piece of approx. length with scissors. 1 cm and the wound is sutured in layers. After 2-3 weeks, after the animal has recovered, the left cervical vagus nerve in the neck is transected.

For long-term survival of dogs with two cut vagus nerves, it is necessary to transect the esophagus for sham feeding, apply a gastric fistula, and carefully monitor the animal's condition.

Transection of both vagus nerves in the lower thoracic region esophagus. After isolating the supraphrenic section of the esophagus, all branches of the vagus nerve running along the esophagus are cut; in addition, the ring must be removed serous membrane covering this area of ​​the esophagus, trying not to injure the muscle layer.

Bibliography: Imperati L., Natale S. and Marinaccio F. Vagotomy of the acid-producing zone of the stomach in the treatment of duodenal ulcer, Surgery, No. 10, p. 93, 1972; Mayat V. S., P a n c y p e v Yu. M. and Grinberg A. A. On the indications and choice of method of surgical treatment of gastric and duodenal ulcers, in the book: Khir. Treatment of gastric and duodenal ulcers, ed. V. S. Mayata and Yu. M. Pan-tsyreva, p. 117, M., 1968; Norknas P.I. and H o r k u s E.P. Experience of 1255 hemigastrectomies with vagotomy, Vestn, hir., t. 104, JVe 1, p. 73, 1970; Pantsyrev Yu. M. et al. Pyloroplasty in combination with vagotomy in the treatment of perforation duodenal ulcer, ibid., t. 109, no. 7, p. 20, 1972; A m d g u p E. a. Jensen H. Selective vagotomy of the parietal cell mass preserving innervation of the undrained antrum, Gastroenterology, v. 59, p. 522, 1970; Dragstedt L. R. a. Owens F. M. Supra-diaphragmatic section of the vagus nerves in the treatment of duodenal ulcer, Proc. Soc. exp. Biol. (N.Y.), v. 53, p. 152, 1943; Dragstedt L.R.a. o. Interrelation between the cephalic and gastric phases of gastric secretion, Amer. J. Physiol., v. 171, p. 7, 1952; Farris J. M. a. S m i t h G. K. Vagotomy and pyloroplasty, Ann. Surg., v. 152, p. 416, 1960; G o 1 i g h e r J. C. a. o. Five - to eight-year results of Leeds/york controlled trial of elective surgery for duodenal ulcer, Brit. med. J., v. 2, p. 781, 1968; Herrington J. L. Antrectomy-vagotomy for duodenal ulcer, N.Y. St. J. Med., v. 63, p. 2489, 1963; H ins haw D. B. a. o. Vagotomy and pyloroplasty for perforated duodenal ulcer, Amer. J. Surg., v. 115, p. 173, 1968; Latarjet A. RSsection des nerfs de l’estomac, Bull. Acad. M6d. (Paris), t. 87, p. 681, 1022; M i 1 1 e g V. a. O. Vagotomy limited to the parietal cell mass. Arch. Surg., v. 103, p. 153, 1971; Weinberg J. A. a. o. Vagotomy and pyloroplasty in the treatment of duodenal ulcer, Amer. J. Surg., v. 92, p. 202, 1956; Welch S. E. Surgery of the stomach and duodenum, Chicago, 1966; Williams J. A. a. C ox A. G. After vagotomy, L., 1969.

V. in the experiment- Bryakin M.I. Vagotomy in experiment and clinic, Alma-Ata, 1969, bibliogr.; Pavlov I.P. Operative methodology for studying the digestive glands, Complete. collection soch., vol. 2, p. 536, M.-JI., 1951, bibliogr.; Serdyuchenko I. Ya. About the asymmetry of the tonic influences of the vagus nerves on the heart, Physiol, journal. USSR, vol. 50, no. 12, p. 1450, 1964, bibliogr.; Speranskaya E.N. Guide to operational methods in physiological experiments, D., 1948.

Yu. M. Pantsyrev; N.K. Saradzhev (V. in the experiment).

When a peptic ulcer occurs, the acidity of the secreted fluid increases gastric juice. This condition is quite dangerous and leads to serious health problems. The ulcer can progress, so when this pathology appears, experts recommend performing an operation called vagotomy. This surgical procedure, during which they are excised, as a result of which the production of hydrochloric acid is stimulated.

Vatotomy and pyloroplasty

It is worth considering in more detail the features of surgical intervention. Vagotomy is an operation during which the vagus (vagus nerve) is excised. Pyloroplasty is a surgical procedure that increases the diameter of the pylorus (the area where the stomach meets the duodenum). Thanks to this, it is possible to improve the process of releasing the gastrointestinal tract. Very often these two operations are performed together.

As a rule, these procedures are prescribed if the patient suffers from a chronic degree of duodenal ulcer or in case of exacerbation of the pathology. Also, vagotomy is the only treatment method if no other therapeutic measures bring visible results for more than 2 years.

It is worth noting that this type of ulcer manifests itself in the form of rather unpleasant symptoms. Patients develop standard dyspeptic symptoms, which manifest themselves in the form of nausea, vomiting, heartburn and belching. Additionally, bloating and problems with bowel movements may appear. This is explained by the fact that a violation of the basic nervous and hormonal mechanisms occurs in the human body.

This can happen against the backdrop of numerous factors. Many people believe that only people who drink too much alcohol suffer from ulcers. However similar pathology may also develop against the background poor nutrition or in case of a disorder of the endocrine system.

It is also worth paying attention to the fact that the level of hydrochloric acid also depends on the innervation to which the vagus nerve leads. It can also negatively affect organ motility. By excision of the entire nerve or its individual branches, it becomes possible to normalize the amount of hydrochloric acid released, so that the pathology can be cured by reducing the aggressive effects of gastric juice.

If the patient is diagnosed with duodenal obstruction, then in this case it is impossible to do without gastric resection, during which the so-called bypass path will be established.

Who is the operation indicated for?

• Non-healing, even taking into account the course of conservative therapy, peptic ulcers.
• Too much frequent relapses illness.
• Occurrence of organ ulcers gastrointestinal tract after undergoing surgery.
• Reflux esophagitis.
• department.

Also, vagotomy with pyloroplasty may be recommended if the patient is diagnosed with an ulcer not only of the duodenum, but also of the stomach. Therefore, the procedure is often performed for stenosis, perforation and bleeding.

However, before surgery, it is necessary to go through everything necessary examinations and consult with a specialist about the advisability of such events.

Contraindications

There are several situations in which gastric vagotomy cannot be performed. For example, performing such an operation is prohibited if the patient suffers from:

• Chronic diseases which may affect various organs and systems in a state of decompensation.
• Acute infectious pathologies.
• Obesity.
• Oncological diseases.
• Intestinal atony.
• Diabetes mellitus.
• Pathologies of blood clotting.

Preparatory procedures

Before performing a gastric vagotomy, it is necessary to prepare for such a procedure. In this case, no special instructions or preparatory procedures are required. Vagotomy is performed in the same way as other types of surgery performed on the gastrointestinal tract. This type of procedure is performed under general anesthesia.

However, although this type of surgery is not complex operation, before performing it, the patient must mandatory pass the laboratory examination. First of all, a complete biochemical analysis blood and also urine. Additionally, it is necessary to check the level of fluid clotting. There should be no surprises during the operation. Therefore, additional instrumental manipulations are also performed. It is necessary to undergo an ECG, X-ray of the lungs and other areas if the doctor suspects that the patient may be suffering from various pathologies.

It would not be superfluous to additionally examine the entire area. This is necessary in order to prevent the opening of nodes during the operation (vagotomy), which could complicate the procedure. As a rule, fibrogastroduodenoscopy is first performed for this purpose. Thanks to this examination, it becomes possible to evaluate the secretory and motor function, as well as the state in which the mucous membrane of the organs is located.

In some situations it is carried out x-ray examination, during which a special contrast agent. Using the resulting image, the specialist accurately determines not only the location of the lesion, but also the depth of the ulcerative defect.

With the help of pH-metry, it becomes possible to clarify the level of acidity of juices secreted into the stomach. After the operation, a similar study is repeated. The doctor compares the levels of indicators. Dynamic monitoring of data before and after surgery becomes possible. Thanks to this data, you can evaluate how effective the operation is.

Types of gastric vagotomy

Today, there are several types of such procedures. Each variety has its own characteristics. The choice of one or another type of vagotomy is made by the doctor. The specialist studies in detail the patient’s medical history, his state of health and many other features. He must make sure that the person does not suffer from serious complications during or after the operation.

Based on the data obtained, the patient may be prescribed a truncal vagotomy, selective (selective) or selective proximal.

In the first case, we are talking about a procedure during which the vagal trunk is excised in the area located above the diaphragm, to the place where the veins branch into smaller processes. Thanks to this, it becomes possible to relieve inflammation from several organs of the digestive system simultaneously. In addition, during the process of truncal vagotomy, this nerve is deprived of innervation, against the background of which desynchronization of the affected organs occurs. First of all, this, of course, concerns the stomach.

First, the surgeon must identify and excise the anterior and posterior branches of the vagus nerve. Typically, the procedure begins with the anterior trunk, which innervates the liver and stomach. After this, the surgeon moves to the back nerve trunk, which is located behind the esophagus. This part is responsible for the innervation of the intestines and pancreas. If necessary, truncal vagotomy with pyloroplasty can be performed. In this case, the gatekeeper will be additionally enlarged.

If we talk about the selective type of procedure, it is somewhat different from the previous method. In progress selective vagotomy Small branches of the nerve that go to the stomach are excised. In this case, manipulations are carried out below the diaphragm. With this procedure, it is possible to preserve the innervation of the organs included in the digestive system.

However, most often doctors perform selective proximal vagotomy. During this surgical procedure, nerve fibers that are directed to the upper part of the stomach are excised. In this case, it is possible to preserve the evacuation function of the affected organ. This makes selective proximal vagotomy the most optimal solution. Such an operation is most often prescribed if the patient suffers from constant relapses of peptic ulcer.

In a highly selective procedure, only the vagal fibers, which are responsible for feeding acid-producing cells, are excised.

Methods for performing the operation

Today, surgery uses the so-called open access (laparotomy), which is more traumatic, and the endoscopic option.

If we talk about the method of excision of nerve fibers, then both a surgical instrument (scalpel) and a method of medicinal-thermal treatment (coagulation) can be used. If the doctor prefers the second method, then the branches of the vagus nerve have a destructive effect with the help of special medications (for example, it can be an alcohol-vocaine hyperionic mixture).

In addition, there is a combined method. In addition to standard tools, specialists use solutions chemical substances. This type of procedure is considered optimal, since in this case it is possible to minimize injuries internal cavities body. However, this method also has one drawback. The fact is that similar procedure takes more time. The operation takes 10-20 minutes longer.

It is worth considering that when carrying out a standard operation during which instruments are used, it is necessary to monitor the level of acidity of gastric juices. Without this, it is very difficult to assess the completeness of the denervation being carried out.

However, it is worth considering that even when carrying out the most gentle and effective procedure, there remains a high risk that problems with the acidity of stomach juice will reappear. According to statistics, in 50% of cases patients are diagnosed with a relapse of peptic ulcer. However, the disease returns after quite a while for a long time. Therefore, it is still possible to temporarily alleviate the patient’s condition.

Disadvantages of the procedure

If treatment of a peptic ulcer is carried out using vagotomy, then you need to know that in this case parasympathetic innervation will be broken. This negatively affects not only those areas where acidity is high, but also other organs of the gastrointestinal tract.

In 4% of operated patients, not only relapses of the pathology, but also serious problems motor-evacuation functions of the stomach. This means that such a procedure may well result in the patient suffering from severe diarrhea, which will also require surgery. Therefore, when deciding to undergo surgery, preference should be given to selective proximal vagotomy for peptic ulcer disease. In this case, there is a much greater chance of avoiding such complications.

If we are talking about a stem-type procedure, then in this case other additional problems may arise. For example, many patients have discovered that they have gallstones several years after surgery.

Additionally, a so-called complex symptom complex may appear. In this case, patients who have undergone surgery complain of increased weakness and rapid heartbeat. After eating, you may experience an upset stomach.

Some people experience duodenogastric reflux. This means that the contents of the duodenum begin to be thrown back into the stomach. This leads to very unpleasant symptoms. Patients experience abdominal pain, vomiting bile, constant feeling bitterness in oral cavity and rapid weight loss.

Duration of hospitalization

If the operation was performed the usual method using instruments, sutures are applied after the procedure. The patient should be at rest and move as little as possible. After about a week, the stitches are removed. However, after this, the patient must remain in the hospital under the supervision of a doctor for 1-2 weeks. This is quite a long time, especially considering that after discharge the patient faces a long recovery period. Full working capacity returns to the patient only after a few months.

If we are talking about more modern procedures, then during laparoscopy sutures are also applied, but they do not need to be removed. The patient can be discharged from the hospital 2-5 days after the operation. After this, he will need about 10-20 days to recover. Thus, determining how long it will take for the patient to return to normal life, you need to take into account the type of procedure.

After operation

As soon as the patient recovers from anesthesia, he must be examined by a doctor. He must make sure that the patient is in satisfactory condition. The first day the patient should remain in bed and not eat anything. It is forbidden to turn around and leave the room. Towards the evening you are allowed to drink some liquid. The patient is allowed to roll over.

The next day he can sit on the bed or try to walk around the ward. He is also given a small amount of semi-liquid food. The patient spends approximately a week in this mode. After this, the patient must adhere to a special diet.

If, in addition to vagotomy, pyloroplasty was performed, then in this case, dietary restrictions will be more stringent. The patient needs to adhere to the diet for about 2-3 weeks.

If we talk about the usual procedures, then in the first weeks you need to be extremely careful when performing hygiene measures. If the patient goes into the shower, then after this it is imperative to treat the body with a 5% solution of potassium permanganate. This is necessary in order to prevent the development of infection.

Finally

Of course, any surgical intervention is dangerous for humans. During the procedure, the specialist may make a mistake or not take into account the presence of additional pathologies in the patient.

Also some people don't tolerate it well general anesthesia. Therefore, before deciding on surgical intervention, the doctor must check the work of cardio-vascular system patient. However, refusing surgery is also dangerous in its consequences. If we admit further development illness, the patient may need urgent hospitalization and more serious surgery.

In this chapter we will focus on the main types of operations associated with the intersection of the vagus nerves (Fig. 1) and used in the treatment of diseases of the digestive system. Issues of pathophysiological justification for the use of vagotomy in surgical gastroenterology, as well as historical references concerning this operation, are not included in a separate chapter, but are covered in the relevant sections of the book as the material is presented.

Truncal subphrenic vagotomy

The technique of trunk subdiaphragmatic vagotomy has been developed quite well, and among all operations associated with the intersection of the vagus nerves, it is the simplest. It was truncal vagotomy with operations that unloaded the stomach in many countries, particularly in the UK, that became the standard intervention for chronic duodenal ulcer.

We, like most surgeons, use an upper midline incision in the anterior abdominal wall. Unlike some authors, we do not see the need for oblique transverse approaches and do not supplement the midline incision with resection of the xiphoid process of the sternum. Some surgeons, for the convenience of surgery, mobilize the left lobe of the liver by crossing its triangular ligament [Shalimov A. A., Saenko V. F., 1972; Tanner N., 1966], however, the need for such a technique arises in some individual cases, more often In most cases, it is enough to move the left lobe of the liver with a retractor. In difficult cases, we use a specially made mirror, which differs from standard retractors in its wider (96 cm) and elongated (160 cm) blade, as well as the inward curvature of its working end to an angle of 25° (Fig. 2, a).

The peritoneum and diaphragmatic-esophageal fascia are dissected over 2-3 cm in the transverse direction at the level of their transition from the diaphragm to the esophagus. To simplify the operation

Rice. L Diagram of the branching of the vagus nerves in the area of ​​the lesser curvature of the stomach.

From the anterior vagus nerve (a) gastric and hepatic branches depart, from the posterior (c) - gastric and celiac branches.

the surgeon, with the palm of his left hand, pulls the stomach down along its lesser curvature, simultaneously fixing the esophagus with the thick esophagus inserted into the lumen gastric tube between the nail phalanges of the third and fourth fingers. Using a gauze pad, the dissected peritoneum and fascia are moved upward. The same tupper is used to clean the side walls of the esophagus, and its muscular layer, on which the anterior vagus nerve is located, becomes clearly visible. The nerve, unlike the esophagus, is not very flexible to stretching, and when the cardiac part of the stomach is displaced down and to the left, it is embedded in the wall of the esophagus in the form of a stretched string, forming a clearly visible groove. This technique facilitates the search not only for the main, but also for additional trunks of the anterior vagus nerve. The nerve trunk is isolated using a dissector or a special hook (Fig. 2, c), intersected or excised for 2 cm between the clamps. To prevent nerve regeneration and prevent bleeding from the accompanying vessels, the ends of the nerve are tied with a thread made of synthetic fibers.

Rice. 2. Instruments that facilitate the performance of trunk subdiaphragmatic vagotomy.

a - retractor; b - spatula; c - hook for isolating the vagus nerve.

The posterior vagus nerve is much thicker than the anterior one; it is most conveniently felt with the third finger of the left hand in the space between the esophagus and the right leg of the diaphragm directly on the aorta. In this place, the posterior vagus nerve passes at the level of the right contour of the esophagus, is not connected with it and is separated from it by a rather dense fascial layer. Sometimes it is more convenient to move the esophagus to the left using a Buyalsky spatula or a special spatula (Fig. 2.6). The nerve is isolated with a dissector or the previously mentioned hook, crossed and its ends are tied with a ligature. During the isolation of the posterior vagus nerve, in order to avoid damage to the wall of the esophagus, the end of the dissector is directed towards the right leg of the diaphragm. For this purpose, even a gentle method of bringing the vagus nerve to a more accessible and safe zone using gauze tuffers [Postolov P. M. et al.,

When searching for the vagus nerve, tension on the stomach along its greater curvature should be avoided in every possible way, since in this case the gastrosplenic ligament is stretched, which can lead to rupture of the splenic capsule.

The operation under the diaphragm is completed by suturing the defect in the diaphragmatic-esophageal fascia and peritoneum. Some authors, to prevent the formation of a sliding hiatal hernia and correct the obturator function of the cardiac sphincter, sew the legs of the diaphragm in front or behind the esophagus with 2-3 sutures, others model the angle of His or perform more complex interventions in the form of Nissen fundoplication. This issue is specifically discussed in Chap. 4.

Truncal vagotomy as a primary operation is always combined with drainage interventions on the stomach or anthrumectomy.

When performing trunk subphrenic vagotomy, it should be remembered that the anterior vagus nerve at the level of the abdominal esophagus passes through one trunk only in 60-75%, and the posterior vagus nerve in 80-90% of patients. In other cases, these nerves are represented here by two or more trunks each [Ivanov N. M. et al., 1988; Scheinin T., Inberg M., 1966]. Leaving additional trunks of the vagus nerve uncrossed can negate the results of surgery.

A huge number of works are devoted to the surgical anatomy of the vagus nerves, and almost every new study reveals previously unknown features of the parasympathetic innervation of the stomach. The number of variants of branching of the vagus nerves at the level of the stomach and the lower third of the esophagus is currently beyond counting, so some authors propose to supplement the intersection of the main and additional trunks of the vagus nerves with various technical tricks, in particular, skeletonization over 5-6 cm of the abdominal esophagus and even circular intersection of its muscular layer at this level. As for skeletonization of the esophagus, this makes sense, since this technique makes it possible to detect and cross some small branches of the vagus nerve and thereby increase the efficiency of the operation. Circular intersection of the muscular layer of the esophagus is a dangerous, and most importantly, useless intervention, since it has been proven that even complete intersection of the esophagus under the diaphragm and destruction of the peri-esophageal tissues do not eliminate vagal stimulation of the stomach. Irritation of the vagus nerve in the neck in these cases causes contraction of the stomach (JeffepsonN.etal., 1967]. It is much more important to know all those places in the area of ​​the cardiac part of the stomach and esophagus where additional branches of the vagus nerve can pass. Such places are the tissue behind the esophagus, where a branch of the posterior vagus nerve may pass, and the space to the left of the esophagus, where sometimes the “criminal” branch G. Grassi (1971) departs from the posterior nerve, going to the fornix of the stomach. In addition, it has been established that as part of the nerve plexus accompanying the right gastrointestinal tract -nic artery, parasympathetic nerve fibers pass through (Kogut B.M. et al., 1980]. Therefore, some authors [Kuzin N.M., 1987] to increase the effectiveness of truncal vagotomy suggest combining it with mobilization of the stomach along the large cri

visna and intersection of the right gastroepiploic vessels. There are operational tests for searching and identifying branches of the vagus nerve, which will be discussed in Chapter 3.