Gastric vagotomy: stem, selective and selective proximal. Complications after surgery

Vagotomy is a surgical operation in the stomach, which consists in the intersection of individual branches or the entire vagus nerve. The presented type of intervention is used for therapy in relation to stomach ulcers, 12 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 are talking about getting rid of reflux esophagitis and other problematic conditions of the esophagus. Vagotomy, as an operation, implies the intersection of the vagus nerve or several of its branches, which stimulate the secretion of hydrochloric acid in the stomach.

The scale of intervention is each time determined individually by a specialist and depends on some features 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 acidic components in the stomach. In addition, it is the presented intervention that provides 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.

Given 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 operations that are used depending on the diagnosis, the existing stomach disease. The classification with which vagotomy is associated will be discussed in more detail later.

The main types of vagotomy

Types of surgery are classified depending on the intervention algorithm, in accordance with this, vagotomy can be of three types: stem, selective and selective proximal. Trunk surgery involves the intersection of the trunks of the vagus nerve. This is carried out directly above the diaphragm area up to the branching of the trunks. Stem vagotomy in this case 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 a selective vagotomy, which cuts absolutely all gastric branches associated with the vagus nerve. Experts pay attention to the following features this type of intervention.

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

It is the selective type of vagotomy that makes it possible to maintain 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 such branches of the vagus nerve that pass to the upper compartments of the stomach are crossed.

This option is estimated by experts today as one of the most preferred. 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, in the treatment of peptic ulcer, 12 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 but pay attention to what complications it may be associated with.

Complications after surgery

In a certain number of patients, despite the implementation of the vagotomy, the production of acid and pepsin is restored after a certain period of time. The consequence of this is that the peptic ulcer recurs. In general, at least 4% of those who have undergone surgery are identified with the most serious 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 sometimes additional surgical intervention is required. In a certain number of patients, after one of the types of surgery, namely the stem type, after two to three years, calculi (stones) are identified in the gallbladder area.

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

As noted earlier, during the dissection of the vagal nerve, a violation of parasympathetic innervation occurs. This is due not only to the production of acid in the stomach, but also affects the rest of its parts. In addition, other organs may be involved. abdominal cavity.

At significant amount 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 enough severe consequences in some cases, it can even lead to death.

Thus, gastric vagotomy is major 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 recommendations of a specialist and consult a doctor in time.

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1. Can cancer be prevented?
The occurrence of a disease such as cancer depends on many factors. No one can be completely safe. But significantly reduce the chances of occurrence malignant tumor everyone can.

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

3. Does it affect excess weight to the development of cancer?
Keep your eyes on the scales! Extra pounds will affect not only the waist. The American Institute for Cancer Research has found that obesity contributes to the development of tumors in the esophagus, kidneys, and gallbladder. The fact is that adipose tissue serves not only to save 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 just appear against the background of inflammation. In Russia, 26% of all cancer cases are associated with obesity.

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

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Less alcohol! Alcohol is blamed for causing tumors in the mouth, larynx, liver, rectum, and mammary glands. Ethanol decomposes in the body to acetaldehyde, which then, under the action of enzymes, passes into acetic acid. Acetaldehyde is the strongest carcinogen. Alcohol is especially harmful to women, as it stimulates the production of estrogen - 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 fruits and vegetables. Especially useful are cruciferous vegetables, which contain glucosinolates - substances that, when processed, acquire anti-cancer properties. These vegetables include cabbage: ordinary white cabbage, Brussels sprouts and broccoli.

7. Which organ cancer is affected by red meat?
The more vegetables you eat, the less red meat you put on your plate. Studies have confirmed that people who eat more than 500 grams of red meat per week have a higher risk of developing colon cancer.

8. Which of the proposed remedies protect against skin cancer?
Stock up on sunscreen! Women aged 18-36 are particularly susceptible to melanoma, the deadliest 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. This is blamed on the equipment for artificial tanning, and Sun rays. The danger can be minimized with a simple tube of sunscreen. A study published in the Journal of Clinical Oncology in 2010 confirmed that people who regularly apply a special cream get melanoma half as often as those who neglect such cosmetics.
The cream should be chosen with a protection factor 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 do not expose yourself to the sun's rays from 10 to 16 hours.

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By itself, stress 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 the immune cells responsible for turning on the fight-and-flight mechanism. As a result, a large amount of cortisol, monocytes and neutrophils, 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, consisting 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 variants of vagotomy, is used to treat gastric and duodenal ulcers, reflux esophagitis, and other acid-related diseases. Code for selective proximal vagotomy (without drainage) A16.16.018.002.

Selective proximal vagotomy compared with other options for vagotomy gives the minimum number of complications. In modern conditions, it is often performed in combination with other operations on the organs of the gastrointestinal tract, including minimally invasive access, laparoscopically, and also in a medical-thermal way.

The difference between selective proximal vagotomy and other types of vagotomy

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, which consists in a disorder of the motility of the stomach and other organs, often manifested in the form of severe diarrhea, as well as other serious complications.

In order to reduce the effect of denervation of gastric areas that do not contain acid-secreting parietal cells, a selective proximal vagotomy operation 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 of regulation of acid neutralization is not disturbed.

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: no 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; the absence of sub- and decompensated forms of duodenostasis. Selective proximal vagotomy must be supplemented with ulcer removal 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 skeletal method is a long, technically complex, expensive surgical intervention and can be successfully performed in specialized medical institutions(O.V. Oorzhak).

Control of completeness of vagotomy

Since the purpose of the operation in selective proximal vagotomy is to cut off the vagal fibers going to the acid-producing fields of the stomach and not cut the rest, the control of the completeness of the vagotomy is the most important component of the operation. Teams of doctors and engineers under the leadership of Corr. 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. Preparations 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 the patient's 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 non-informative and is not carried out. 3-45 minutes after the administration of pentagastrin (histamine), secretion stimulation continues throughout the operation. During and after vagotomy, careful aspiration of gastric contents through a probe is performed. After performing selective proximal vagotomy, the measurement of mucosal acidity is achieved by the surgeon by pressing the antimony electrode against the stomach wall without excessive pressure along four main lines - lesser and greater curvature, anterior and back wall. In the presence of secreting fields, an additional intersection of intact nerve fibers and repeated control of vagotomy are performed. Vagotomy is considered complete with an increase in pH over the entire surface of the gastric mucosa to 5 or more (Yu.M. Pantsyrev, S.A. Chernyakevmch, I.V. Babkova, 1999).


		intraoperative pH probe with buccal calomel reference electrode and channel for aspiration of gastric contents

Professional medical publications concerning 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 // Zdravookhraneniye i medtekhnika. - 2004. - No. 4. - p. 22–23.

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

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

V. suppresses the secretion of the stomach in response to imaginary feeding, and its emptying in the first period after the operation is much slower. It was also noted that the transection of the vagus trunks at the level of the diaphragm does not lead to any serious violations respiration 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 the technique of the operation 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 large clinical material. Experimental studies have shown that the intersection of wandering 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 revealed a sharp decline after V. 12-hour nocturnal secretion of hydrochloric acid (so-called basal secretion) in patients with ulcers. The gradual increase in acid production, sometimes observed after this operation, is directly related to the violation of evacuation from the vagotomized stomach, resulting in a secondary stimulation of the hormonal phase of secretion. As a result, pronounced dyspeptic phenomena, lack of healing or even recurrence of the ulcer are observed. It is for this reason that most authors consider one V. without the accompanying draining (facilitating evacuation) interventions on the stomach as an operation that does not provide a reliable effect and, therefore, is unacceptable for the treatment of peptic ulcer.

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

B. and economical resection of the stomach (hemigastrectomy, antrumectomy) is used as one of the methods of surgical treatment of complicated duodenal ulcers. During 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 (nerve reflex) and in the second (humoral) phase.

In the practice of surgical treatment of peptic ulcer for each operation mentioned there are indications; the right method can provide maximum effect in relation to the cure of ulcers 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 at the same time. With stem (truncular) V., the vagus trunks usually cross 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 in the intersection of all gastric branches of the vagus trunks, while the functionally important branches leading 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., as diarrhea, dysfunction of the pancreas, gallbladder and biliary tract. Finally, with the so-called proximal gastric V., the branches of the vagus nerves selectively intersect only to the upper sections of the stomach. This operation achieves partial denervation of the stomach only in the zone of distribution of acid-producing (parietal) cells of the mucous membrane, in connection with which some authors call it "selective vagotomy of the parietal cell mass" [Amdrup and Griffith (V. M. Amdrup, C. A. Griffith 1969]. Preservation of the vagal innervation of the antrum of the stomach provides, 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 resistant 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 (draining operations or economical resection). At the same time, in cases of complicated duodenal ulcers (stenosis, penetration), an economical resection should be performed, with an uncomplicated ulcer, various types pyloroplasty.

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

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

Operation technique

Preparation for operation does not differ in any features and consists of the elements providing carrying out an operative measure on went. - kish. tract. Pain relief is general.

Transperitoneal vagotomy. The most convenient access to the subphrenic space is provided by the upper median incision. The esophageal opening of the diaphragm is opened for review after the left lobe of the liver is retracted with a long retractor, which is facilitated by mobilization of the lobe by dissection of the triangular ligament of the liver.

Stem vagotomy. To perform stem V., it is necessary to isolate the nerve trunks just above the diaphragm, even before they divide into branches. After dissection of the sheet of peritoneum covering the diaphragm at the edge esophageal opening, the surgeon in a blunt way allocates the anterior and posterior trunks of the vagus nerves from the paraesophageal tissue. Sipping on the stomach facilitates the search for nerve trunks, which can often be multiple.

First, the anterior and then the posterior vagus trunk is 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 that run at this level are crossed, since the effectiveness of the operation depends on the completeness of V..

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

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

Selective (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., is still holding back surgeons from its widespread use.

To perform selective V., a good knowledge of the anatomical details of the branching of the vagus trunks and their relationship with the vessels of the lesser curvature of the stomach is necessary, only under this condition is it possible to completely cross all the 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 stem V., all manipulations with the aim 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 smallest 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 superimposed clamps, in which small vascular and nerve branches pass to the lesser curvature of the stomach (Fig. 2). All branches captured by the clamps are carefully tied up.

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

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

Proximal selective vagotomy. During this operation, the nerve trunks that pass along the lesser curvature to the corner of the stomach along with the descending branches of the vessels (the so-called nerves of the lesser curvature of Latarjet) are preserved. The distal border of the 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 precisely with the help of 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 smallest curvature is continued up to the cardia and further to the fundus of the stomach at its junction with the esophagus (angle of His).

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

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 provides completeness of gastric V. and excludes undesirable complications.

The postoperative period in patients after surgery on the stomach with the use of V. does not differ significantly from the postoperative period after conventional resection of the stomach.

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 section. Short-term drainage of the stomach with a nasogastric tube or through a temporary gastrostomy usually prevents or quickly eliminates this complication.

Late complications or disorders caused by V. are reduced to a symptom complex, which has received the name "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 Post-gastroresection syndrome), diarrhea. According to a number of researchers [Cox (A. G. Cox), 1968; Goliher (J. C. Goligher) et al., 1968], who specially studied this issue, the incidence of post-vagotomy syndrome after V. in combination with draining operations is 10%. There are 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 ulcer should be considered satisfactory. So-called, the sparing operations on a stomach in combination with V. give lower lethality, than subtotal resections. Mortality after draining operations in combination with V., according to domestic and foreign surgeons, is 0.5-1.0%. Negative side these operations remains a relatively high percentage of ulcer recurrence (4-8%), according to Williams (J. A. Williams) and Cox.

Vagotomies in the experiment

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

The preparation of the vagus nerve in the neck in warm-blooded animals (dog, cat, rabbit) is performed under surface anesthesia. The approach to the nerve is carried out by 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 pushing these muscles apart at the bottom of the wound, lateral to the trachea and 1 cm caudal to the larynx, they feel for the common carotid artery, which, together with the neurovascular bundle, is bluntly separated from the surrounding tissue and lifted with a ligature. The vago-sympathetic trunk soldered with it is dissected from the vessels and taken for a ligature. The dense connective tissue sheath of the vago-sympathetic trunk in dogs is opened with a longitudinal incision with a sharp eye scalpel and the vagus nerve is exfoliated from it, which has a white color with a mother-of-pearl tint. cervical fibers sympathetic nerve while remaining in the thickness of the connective tissue membrane. In cats and rabbits, these nerves are easily divided in a blunt way.

For sharp experiments, eg. for electrical stimulation of the central or peripheral end of the cervical vagus nerve, middle part the selected section of the nerve is crossed between two ligatures.

In a semi-chronic experiment, the nerve is cut 1-2 days after the operation, when the animal has fully recovered from anesthesia and trauma. To do this, the vagus nerve is dissected as far as possible, after cutting the sternohyoid muscle. A ligature is brought under the nerve, the nerve and the ligature are placed under the skin. skin wound sew up. On the day of the experiment, before the experiment, several skin sutures are removed and the nerve is pulled out by the ligature for its quick cutting 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 skin Filatov stalk. In this case, a modification of the Van Leersum operation is used, which is usually used to remove the common 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 together with the vagus nerve. A thin-walled rubber cuff sewn into a nylon case is put on the selected skin tube, water is passed through it 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 a vagus nerve for hron, experiments should be made extremely carefully since its strong irritation quite often leads to hypostasis of lungs or pneumonia and to death of an animal (AV Thin, 1949). For the same reason, animals do not tolerate simultaneous cutting of both vagus nerves in the neck.

If for hron, experiments on dogs bilateral V. is necessary, for example, for studying of functions of bodies digestive tract, kidneys, etc., it is produced in two stages.

During the first operation, the right vagus nerve is cut in the area 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 sternomastoideus 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 vago-sympathetic trunk. The nerve is taken to the ligature and, moving up and to the side of the large chest muscle open the entrance to the chest cavity. With long hooks in good light, expand the wound and dissect the nerve to 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 brought under the trunk of the vagus nerve, located caudal to the origin of the subclavian loop. Continuing the blunt preparation of the trunk of the vagus nerve, isolate it at the greatest possible distance, cut out with scissors a piece approx. 1 cm and the wound is sutured in layers. After 2-3 weeks, after the recovery of the animal, the left cervical vagus nerve is cut in the neck.

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

Transection of both vagus nerves in the lower thoracic region esophagus. After isolating the supradiaphragmatic esophagus, all branches of the vagus nerve going through the esophagus are cut; in addition, it is necessary to remove the ring serous membrane covering this area of the esophagus, trying not to injure the muscle layer.

Bibliography: Imperati L., Natale C. 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 and n s y p e in Yu. M. and Grinberg A. A. About the indications and the choice of the method of surgical treatment of gastric ulcer and duodenal ulcer, in the book: Khir. treatment of peptic ulcer of the stomach and duodenum, ed. V. S. Mayat and Yu. M. Pan-tsyreva, p. 117, M., 1968; Norknas P. I. and H about r to at with E. P. Experience of 1255 hemigastrectomy 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 perforated duodenal ulcer, ibid., vol. 109, no. 7, p. 20, 1972; A m d g u p E. a. Jensen H. Selective vagotomy of the parietal cell mass preservation 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. Sm 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; Hins 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 B. 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 C. E. Surgery of the stomach and duodenum, Chicago, 1966; Williams J. A. a. C ox A. G. After vagotomy, L., 1969.

V. in experiment- Bryakin M.I. Vagotomy in experiment and clinic, Alma-Ata, 1969, bibliogr.; Pavlov IP Operative technique of studying of digestive glands, Poln. coll. cit., vol. 2, p. 536, M. - JI., 1951, bibliogr.; Serdyuchenko I. Ya. About asymmetry of tonic influences of wandering nerves on heart, Fiziol, zhurn. USSR, vol. 50, no. 12, p. 1450, 1964, bibliography; Speranskaya E.N. Guide to operational methods in a physiological experiment, D., 1948.

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

In the event of a peptic ulcer, the acidity of the excreted gastric juice. This condition is quite dangerous and leads to serious health problems. The ulcer can progress, therefore, 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 liberation of 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 method of treatment if no other therapeutic measures bring a visible result 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 stools may appear. This is due to the fact that in the human body there is a violation of the main nervous and hormonal mechanisms.

This can happen due to many factors. Many believe that only people who drink too much alcohol suffer from ulcers. However similar pathology may develop in the background malnutrition or if the endocrine system is disturbed.

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 the motility of organs. When the entire nerve or its individual branches are excised, 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 obstruction of the duodenum, then in this case it is impossible to do without a resection of the stomach, in which the so-called bypass will be established.

Who is the operation for?

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

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

However, before surgery, it is necessary to go through all necessary examinations and consult with a specialist on the appropriateness of such events.

Contraindications

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

chronic diseases which may affect various bodies and systems that are in a state of decompensation.
Acute infectious pathologies.
Obesity.
Oncological diseases.
Atony of the intestine.
Diabetes.
Pathologies of blood clotting.

Preparatory procedures

Before performing a gastric vagotomy, it is necessary to prepare for such a procedure. In this case, it is not necessary to follow special instructions and preparatory procedures. 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 complicated operation, before performing it, the patient must without fail pass the laboratory examination. First of all, a complete biochemical analysis blood as well as urine. In addition, it is necessary to check the level of coagulability of the liquid. There should be no surprises during the operation. Therefore, additional instrumental manipulations are also performed. It is necessary to undergo an ECG, take an x-ray of the lungs and other areas if the doctor has a suspicion that the patient may be suffering from various pathologies.

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

In some situations, there is x-ray examination, during which a special contrast agent. On the resulting image, the specialist accurately determines not only the location of the lesion, but also the depth of the ulcer.

With the help of PH-metry, it becomes possible to clarify the level of acidity of the juices secreted into the stomach. After the operation, such a study is repeated. The doctor compares the levels of indicators. It becomes possible to dynamically control data before and after surgery. Thanks to these data, you can evaluate how effective the operation is.

Types of gastric vagotomy

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

Based on the data obtained, the patient may be assigned a stem 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 point where the veins branch into smaller processes. Thanks to this, it becomes possible to remove inflammation from several organs of the digestive system at the same time. In addition, in the process of stem vagotomy, this nerve loses its innervation, against the background of which desynchronization of the affected organs occurs. First of all, of course, this concerns the stomach.

First, the surgeon must isolate and excise the anterior and posterior branches of the vagus nerve. As a rule, the procedure begins with the anterior trunk, which innervates the liver and stomach. After that, the surgeon proceeds 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, a stem vagotomy with pyloroplasty can be performed. In this case, the gatekeeper will be additionally increased.

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

However, most doctors perform selective proximal vagotomy. In the process of such a surgical intervention, nerve fibers are excised, which are sent to the upper part of the stomach. 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 recurrences of peptic ulcer.

With a highly selective procedure, only the vagal fibers, which are responsible for the nutrition of acid-forming cells, are excised.

Operation methods

To date, 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 medical-thermal exposure (coagulation) can be used. If the doctor prefers the second method, then the branch of the vagus nerve has a devastating effect with the help of special medications (for example, it can be an alcohol-based 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 organism. However, this method has one drawback. The fact is that similar procedure takes more time. The operation takes 10-20 minutes longer.

It should be borne in mind that during 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 ongoing denervation.

However, it should be borne in mind that even with the most gentle and effective procedure, there remains a high risk that problems with the acidity of gastric 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 for a long time. Therefore, it is still possible to temporarily alleviate the patient's condition.

Disadvantages of the procedure

If the treatment of peptic ulcer is carried out with the help of 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 increased, but also in other organs of the gastrointestinal tract.

In 4% of the operated patients, later on, not only recurrences of the pathology were manifested, but also serious problems motor-evacuation functions of the stomach. This means that such a procedure may well lead to the fact that the patient will suffer from a severe form of diarrhea, which will also require surgical intervention. Therefore, when deciding on an operation, preference should be given to selective proximal vagotomy in case of peptic ulcer. In this case, it is much more likely to avoid such complications.

If we are talking about a stem-type procedure, then other additional problems may appear in this case. For example, many patients have encountered the fact that several years after surgery, they found stones in the gallbladder.

Additionally, a so-called complex symptom complex may appear. In this case, patients who underwent surgery complain of increased weakness, palpitations. After eating, indigestion may begin.

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

Duration of hospitalization

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

In more modern procedures, stitches are also applied during laparoscopy, but they do not need to be removed. The patient can be discharged from the hospital as early as 2-5 days after the operation. After that, he will need about 10-20 days to recover. Thus, determining how long the patient can return to normal life, you need to consider the type of procedure.

After operation

As soon as the patient wakes up from anesthesia, he must be examined by a doctor. He must make sure that the patient is in a satisfactory condition. The first day the patient should be in bed and eat nothing. It is forbidden to turn around and leave the room. Toward evening, it is allowed to drink a little liquid. The patient is allowed to roll over.

The next day, he may sit on the bed or try to walk around the room. He is also given a small amount of semi-liquid nutrition. In this mode, the patient spends about a week. After that, 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 a diet of about 2-3 weeks.

If we talk about the usual procedures, then the first weeks you need to be extremely careful when performing hygiene measures. If the patient goes to the shower, then after that it is necessary 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 a person. In the process of performing the procedure, the specialist may make a mistake or not take into account the presence of additional pathologies in the patient.

Some people also don't tolerate well. general anesthesia. Therefore, before making a decision on surgical intervention, the doctor must check the work of cardio-vascular system patient. However, the refusal of the operation is also dangerous in its consequences. If we allow further development disease, 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 the pathophysiological substantiation of the use of vagotomy in surgical gastroenterology, as well as historical references regarding this operation, are not taken out in a separate chapter, but are covered in the relevant sections of the book as the material is presented.

Stem subphrenic vagotomy

The technique of stem subdiaphragmatic vagotomy is well developed, and among all operations associated with the intersection of the vagus nerves, is the simplest. It is the stem vagotomy with unloading stomach operations in many countries, in particular in the UK, that has become the standard intervention for chronic duodenal ulcer.

We, like most surgeons, use the upper median incision of the anterior abdominal wall. Unlike some authors, we do not see the need for oblique approaches and do not supplement the median incision with resection of the xiphoid process of the sternum. Some surgeons, for the convenience of operating, 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 however, 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 a wider (96 cm) and elongated (160 cm) blade, as well as inward curvature of its working end up to an angle of 25° (Fig. 2a).

The peritoneum and diaphragmatic-esophageal fascia are dissected for 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 Scheme of branching of the vagus nerves in the region of the lesser curvature of the stomach.

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

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 III and IV fingers. The dissected peritoneum and fascia are shifted upwards with a gauze tupfer. The side walls of the esophagus are cleaned with the same tupfer, while its muscular layer, on which the anterior vagus nerve is located, becomes clearly visible. The nerve, unlike the esophagus, is not very pliable to stretching, and when the cardial section of the stomach is displaced down and to the left, it is introduced into 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. 2c), crossed or excised for 2 cm between clamps. To prevent regeneration of the nerve and prevent bleeding from the vessels accompanying it, the ends of the nerve are tied with a thread of synthetic fibers.

Rice. 2. Instruments that facilitate the performance of stem 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 gap between the esophagus and the right crus 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 sheet. Sometimes it is more convenient to move the esophagus to the left using Buyalsky's 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 exposure 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 crus of the diaphragm. For this purpose, even a sparing method has been proposed to bring the vagus nerve into a more accessible and safe zone with the help of gauze tupfer [Postolov P. M. and others,

When looking for the vagus nerve, you should avoid stretching the stomach along its greater curvature, since in this case the gastrosplenic ligament is stretched, which can lead to rupture of the spleen capsule.

The operation under the diaphragm is completed by suturing the defect in the diaphragmatic-esophageal fascia and peritoneum. Some authors, in order to prevent the formation of a sliding hernia of the esophageal opening of the diaphragm and correct the obturator function of the cardiac sphincter, suture the pedicle 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 a Nissen fundoplication. This issue is dealt with specifically in Chap. 4.

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

When performing stem subphrenic vagotomy, it should be remembered that the anterior vagus nerve at the level of the abdominal esophagus passes through one trunk in only 60-75%, and the posterior one - 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 surgical intervention.

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 no longer countable, 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 muscle layer at this level. As for the skeletonization of the esophagus, this makes sense, since this technique allows you to detect and cut some small branches of the vagus nerve and thereby increase the efficiency of the operation. Circular transection of the muscular layer of the esophagus is a dangerous and, most importantly, useless intervention, since it has been proven that even complete transection of the esophagus under the diaphragm and destruction of the periesophageal tissues do not eliminate gastric vagal stimulation. Irritation of the vagus nerve in the neck in these cases causes contraction of the stomach (Jeffepson N. et al., 1967]. It is much more important to know all those places in the cardial region of the stomach and esophagus where additional branches of the vagus nerve can pass. Such places are the fiber behind the esophagus, where a branch of the posterior vagus nerve can pass, and the space to the left of the esophagus, where sometimes the “criminal” branch departs from the posterior nerve G. Grassi (1971), going to the fornix of the stomach. - nic artery, parasympathetic nerve fibers pass (Kogut B.M. et al., 1980]. Therefore, some authors [Kuzin N.M., 1987] propose to combine it with mobilization of the stomach along a large cr

vein 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.