Complications after selective proximal vagotomy. Vagotomy for gastric and duodenal ulcers

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 secretion of hydrochloric acid in the stomach area.

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 to 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 stomach 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 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) of 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 normal functioning 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, a violation occurs parasympathetic innervation. 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 oncological diseases. 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! Overweight will affect not only the 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. American cancer society recommends training 150 minutes a week at a moderate pace or half as much, but more actively. 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.

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Selective proximal vagotomy - surgery, one of the operations options 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 code proximal vagotomy(without drainage) A16.16.018.002.

Selective proximal vagotomy, compared with other vagotomy options, produces a minimal number of complications. IN modern conditions 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 classic version 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 of the 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 at surgical treatment"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 time-consuming, technically complex, and 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. From preoperative preparation drugs that affect gastric secretion are excluded. 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.

Previously, the treatment method for peptic ulcers of the stomach and duodenum was partial removal stomach. But large percentage deaths forced doctors to look for alternatives, and vagotomy replaced resection.

Gastric vagotomy is a surgical operation in the abdominal area, which involves cutting the trunk of the vagus nerve or its individual branches that promote the production of hydrochloric acid to reduce the overall acidity of the digestive tract.

This operation acquired greatest distribution in the seventies of the last century, then it was partially replaced by drugs that reduce acid secretion, but in some cases vagotomy - the only way relieve the patient from a particular disease. The need for, scale and type of surgery are determined by the doctor individually based on existing contraindications and current state sick.

Types of vagotomy

The procedure is carried out under general anesthesia. Preparation for it occurs in the same way as for other operations. gastrointestinal tract. There are several types of surgery based on the degree of denervation:

1. Stem. The surgeon crosses the trunk of the vagus nerve, as a result of which denervation occurs not only of the stomach, but also of all organs located under the diaphragm. This leads to the formation of the so-called post-vagotomy syndrome, which destabilizes the functioning of the stomach. This operation is always performed in combination with drainage operations, such as widening the passage between the stomach and duodenum or creating an artificial anastomosis between them.
2. Selective. Characterized by complete denervation of only the gastric region with preservation of the nerve branches going to the liver and solar plexus. In this case, the functionality of the pylorus is impaired, so the surgeon also performs a drainage operation. TO this species are rarely resorted to, since it does not have any special advantages over the first, while, with technical point vision, it is much more difficult to perform.
3. Selective proximal. As part of this surgical intervention, only those branches of the nerve that go to the upper sections digestive organ. It is this type that doctors rate as the most optimal, since it allows you not to lose digestive functions and does not require drainage. But it is also the most difficult to perform, and is also not always possible in case of serious complications.

Access operations are also distinguished:

1. Open vagotomy.
2. Laparoscopic vagotomy.

Indications for surgery

Although this operation is not used so often, it is the most optimal of surgical methods interventions. The specialist prescribes it in the following cases:

• ineffectiveness of drug treatment;
• individual intolerance to the drugs used;
• refusal of the patient from long-term and expensive drug treatment;
• continuous relapses of the disease;
• perforation of ulcerative formations;
• hemorrhage from a peptic ulcer.

Research is also being conducted into the use of vagotomy to combat obesity. As a result of its use, an average of 18% weight loss is observed. Depending on what was the reason for prescribing the procedure, one of the types of its implementation is selected.

Contraindications

Stomach operations have a characteristic number of contraindications:

• heavy physical state patient;
• acute infections;
• poor blood clotting;
• intestinal atony;
• ulcers with reduced secretion;
• obesity of the third and fourth degree.

In urgent situations, the patient is operated on despite contraindications, unless the likelihood of death is too high.

Postoperative period

Recovery after vagotomy occurs without much difference from recovery after other operations of the gastrointestinal tract. Basically, problems arise due to the operations that accompany it and which it complements: resection, pyloroplasty, anastomosis. After the procedure, a twelve-hour study of gastric secretion is carried out to ensure that the vagotomy was complete.

For a week, a nasogastric tube is placed in the esophagus and inserted parenteral nutrition, the contents of the stomach are sucked out until it can push the contents further through the intestines. Then the patient begins to take liquid food in moderate portions. As with an ulcer, it is necessary to strictly observe for a month limited diet With frequent meals, to digestive system adapted to new conditions.

Complications after surgery

Along with the complexity of carrying out, significant reason refusal from the widespread use of vagotomy is big list complications encountered by patients:

• suture dehiscence at the sites of pyloroplasty;
• restoration of acid production;
• gastric atony and food retention, sometimes a complete stop of the gastrointestinal tract;
• difficulty swallowing;
• damage and necrosis of the stomach walls;
• reverse bile flow;
• accelerated ejection undigested food into the intestines;
• diarrhea due to post-vagotomy syndrome (most often found in stem and selective types operations).

Among more late complications meet:

• relapses peptic ulcers(with incomplete vagotomy);
• development of anastomotic ulcer (during gastrojejunostomy);
• increasing number of cases cholelithiasis(due to cutting off the branch of the nerve leading to the gallbladder);
• malignant formations in the gastric region.

According to various sources, 5-30% of patients who have undergone surgery suffer from post-vagotomy syndrome. Similar complications are treated with medication, but in some cases (with relapses of ulcerative formations) repeated surgery is necessary.

So, vagotomy allows you to restore the functionality of the stomach and help get rid of various pathologies. But interference with work internal organs can provoke unpredictable complications, including relapse of the disease. You should strictly follow all doctor’s prescriptions and promptly contact specialists in case of complications.

Vagotomy is a surgical process, intervention in the stomach cavity for ulcers, disorders of the esophagus and duodenum. The operation reduces excess secretion of hydrochloric acid. The gastric reservoir is preserved in whole or in part, as well as sufficient quantity acids for normal digestion.

Vagotomy involves cutting off the branches of the vagus nerve (vagus) responsible for stimulating secretion gastric juice. Thanks to the operation, the production of acidic juice in the stomach is reduced, the effect on the intestinal mucosa is reduced, and ulcers heal.

Ulcer treatment is carried out according to several schemes. There are stem, selective and selective proximal vagotomy.

Truncal surgery is a process in which the vagal trunk is intersected above the diaphragm area to the site of division of the trunks. Leads to a break in innervation, to disruption of the integrity of connections between organs, tissues and nervous system. Impossible without subsequent drainage manipulations.

The selective method consists of cutting the gastric branches and preserving their part directed to the hepatic region and solar plexus. An incision is made under esophageal hiatus diaphragm.

The proximal selective method allows you to cross the parts of the vagus directed towards the upper part of the gastric reservoir, thereby preserving the original gastric and alimentary tract to the greatest extent. Proximal vagotomy affects areas containing acid-producing cells. With this type, there is no need to resort to drainage surgery.

Choosing a method of operation

Morphology ulcerative inflammation, localization and parameters of the gastrointestinal tract and secretion influence the choice of method of operation:

• if the ulcer affects the stomach directly, resection of two thirds or three quarters of the stomach is performed;
• at duodenal disease Vagotomy is performed to exclude increased secretion of the neuro-reflex phase;
• when acute complications ulcers, stem surgery is preferable;
• elective operations involve a selective method of procedure with the least denervation.

In each specific case, the choice of stem or selective method is very controversial. The stem circuit is easier to perform, but less physiological than selective surgery. When it comes to urgency surgical intervention at acute ulcer, preference is given to truncal vagotomy as more emergency method. Postbulbar peptic ulcer disease, age-related operated and complex accompanying illnesses are considered the reason for mandatory drainage surgery.

A low-lying gastric ulcer will be an indication for antral resection. The operation is performed by surgical cutting of the vagus and medicinal-thermal, destroying the branch of the vagus gastric nerve with a combination of alcohol-vocaine hyperionic solution and electrothermal electrocoagulation reactions.

Disadvantages of vagotomy schemes

All three ulcer treatment options have disadvantages, modern medicine moves away from the schematic treatment of ulcers, preferring individual approach depending on the reasonable indications of the patient.

Practice shows that during stem surgery, the hepatic and celiac branches of the vagus intersect, the consequences are the manifestation of post-vagotomy syndrome, the absence of high-quality connections between the liver and pancreas and the central nervous system. To avoid negative consequences operations, in addition to the usual open method laparoscopic vagotomy is used.

Technique for performing vagotomy for ulcers

Minimally invasive surgery methods are becoming increasingly popular and are replacing classic types operating. Achievement therapeutic effect with minimal trauma and damage to neighboring organs and tissues is the main task modern treatment ulcers. High-precision instruments and surgical devices have made laparoscopy widespread.

Surgery using laparoscopy is performed with the patient lying on his back, legs spread apart, and the end of the table raised from his head. The surgeon stands between the legs of the person being operated on, his assistant stands to the right of the patient.

Laparoscopy uses:

• surgical scissors;
• dissector;
• traumatic clamps;
• electrosurgical hooks;
• clip applicator;
• retractors of the legs of the diaphragm.

Medical trocars are located according to anatomical points. A ten-millimeter trocar 30 optics is installed five centimeters above the left of the umbilical cavity. Trocars for manipulation are inserted under the xiphoid process, five to six centimeters to the right and above the umbilical cavity under the left arch of the rib on the middle clavicle strip.

Having finished checking anatomical position, the first part of the stem surgery is performed - posterior vagotomy.

Posterior truncal vagotomy

The left part of the liver is retracted from the subxiphoid trocar using a retractor. A clamp is inserted on the left side of the hypochondrium, deflecting below the abdominal part of the esophagus. Traction of the cardiac compartment is performed along the axis of the esophagus to avoid damage to the vessels of the lesser curvature of the stomach. The peritoneum straightens out along with the fiber from the top of the omentum.

The diaphragmatic right leg of the lesser omentum is opened and stretched perpendicularly, and the Right side omental bursae near the hepatogastric nerve endings.

The purpose of the posterior truncal transection procedure is right leg diaphragm and Spigelian lobe of the liver. In the process, the peritoneum around the esophagus is stretched, as a result it is possible to reach the tissues of the gastrointestinal tract.

At this stage of the operation, a whitish bright line clearly appears - the vagus nerve, which is captured with a clamp and separated from the vessels with a coagulation surgical hook with a dissector.

About a centimeter of the vagus is cut out between the clips, then sent for histological laboratory examination.

Selective dissection of the gastric branches of the anterior vagus

The second stage is selective cutting of the branches of the stomach of the anterior vagus. An anti-traumatic clamp is used to examine the omentum lower into the corner of the stomach to the location of the “crow’s foot” - the terminal branch of the anterior nerves of the stomach.

Revealed in to the greatest extent the cranial part of the crow's foot, the gastric part of the nerve is crossed upward near the stomach. Each nerve supplied to the antrum and pylorus remains intact.

The peritoneum is advanced higher and the peritoneum is cut, after which the muscular part of the lesser curvature is exposed.

At the location of the cardia, the dissection deviates to the left downward from the previous line, and an incision is made in the abdominal part of the esophagus. extreme point cut - the vertex of the angle. The main task is to cut all the fibers that branch in the left part of the vagus.

In some cases, peritonization of the lesser curvature is performed or a simpler version of selective surgery is performed - linear seromyotomy, using a mechanical suture. In this case, painstaking dissection is excluded. At 6-7 cm from the location of the pylorus, the anterior wall of the stomach is fastened with a linear stitching device to the esophagus. The seam runs 2-3 cm parallel to the lesser curvature.

Laparoscopic vagotomy for peptic ulcer is not only effective, but also allows you to cause the least harm to the body due to the absence of large incisions and quick recovery period, wherein high price stitching tools and cassettes makes it quite expensive.

The effectiveness of vagotomy

After surgery, peptic ulcer disease can recur. The secretion of acids and the enzyme of the gastric mucosa (pepsin) tends to resume in the same volume over time. 4% of those operated on complain of nausea, bloating, and diarrhea associated with the disorder motor function gastrointestinal tract. Frequent heartburn, vomiting, belching, and a feeling of premature satiety are signs that reoperation may be required.

Some of the patients who underwent truncal vagotomy, contacted medical institutions with stones formed in gallbladder 2-3 years after surgery. Ulcerative relapse most often occurs after stem surgery. Not enough complete surgery or failure of the sutures can lead to postoperative hernias.

Checking the completeness of vagotomy

Relapses and complications may be associated with insufficient effectiveness and completeness of the procedure. One of the main stages of surgery for peptic ulcer disease is checking the completeness of the vagotomy performed. This control is carried out in several ways. The most effective is pH-metry, which is a measurement of the acidity level of the stomach. The main task of such a test is to find out whether all vagal fibers are suppressed and whether there are any acid-producing cells.

Monitoring of acidity and completeness of vagotomy is carried out at the end of the operation with a measuring electrode pressed to the wall of the stomach along the lines:

• great curvature;
• small curvature;
• front wall;
• small wall.

If an area with acid production is detected, the vagal fibers are additionally cut off and the completeness of the vagotomy is checked again. The operation is considered successful if the pH of the entire gastric mucosa is at least 5.

Modern emergency rooms often use a stem laparoscopic procedure and drainage surgical intervention in combination to achieve maximum elimination of subsequent complications.

Selective proximal vagotomy, proposed by FiHolle and W. Hart (1964), has a number of other names, such as parietal cell vagotomy (C. Griffith), superselective vagotomy (C. Grassi), highly selective vagotomy, parietal cell, proximal vagotomy [Sibul U., 1985], etc. This operation provides for parasympathetic denervation of the body and fundus of the stomach with preserved innervation of its antrum. The authors of the operation in all cases combine selective proximal vagotomy with pyloroplasty, however, over time, in the absence of an obstruction in the gastric outlet, most surgeons began to use this intervention in its “pure” form, and only for duodenal ulcers.

duodenal ulcer complicated by stenosis, it is supplemented by drainage surgery on the stomach.

Before proceeding with denervation of the body and fundus of the stomach, it is necessary to mark the proximal border of the antrum of the stomach. The method for determining its extent using various functional tests is described in Chapter. 3. Here we point out that most surgeons use external anatomical landmarks. On the lesser curvature of the stomach, such a landmark is the place where the terminal branches of the anterior nerve of Latarget, branched in the form of a “crow’s foot,” are introduced into the stomach wall in the region of its angle. The blood vessels that run along with the nerves divide in the same way at this location, making the crow's foot especially noticeable. On the greater curvature of the stomach, the upper border of the antrum is \ roughly corresponds to the so-called Gotham point, at which the right and left gastroepiploic arteries join. Denervation of the stomach begins from the crow's foot and ends in the area of ​​the angle of His. To avoid preserving the innervation of the acid-producing zone of the stomach, 1-2 distal branches of the Latarjet nerves are left uncrossed, and all other branches of the crow's foot are crossed. The technique of selective proximal vagotomy, as well as selective vagotomy, consists of step-by-step skeletonization of the lesser curvature of the stomach and the abdominal esophagus over a length of 5-6 cm, restoration of the serous cover of the stomach and esophagus, and suturing of the lesser omentum to the stomach (Fig. 3).

The technical complexity of traditional selective proximal vagotomy makes it almost unacceptable in emergency surgery, in obese patients, as well as in people with severe concomitant diseases, for whom the duration of the operation is of considerable importance. To simplify the operation, changes have been made to the technique of selective proximal vagotomy by different authors. Thus, some surgeons cross the posterior Latarget nerve and preserve the anterior one, considering this sufficient for adequate motility of the antrum of the stomach (Senyutovich R.V., Alekseenko A.V., 1987); others combine anterior selective proximal vagotomy with the posterior trunk (Velichko V. M. et al., 1987; Manevich V. L. et al., 1987; Hill G., Barker M., 1978].

As experience accumulated and observation periods increased for patients who had undergone proximal vagotomy, other disadvantages of this operation began to be discovered, the most serious of which was the high rate of ulcer recurrence. This circumstance forced them to look for ways to increase the effectiveness of the operation. In particular, some surgeons began to combine selective proximal vagotomy with segmental gastrectomy, including

b

Rice. 3. Scheme of proximal selective vagotomy.

a - the dotted line indicates the proximal border of the antrum of the stomach, arrows indicate the zone of skeletonization of the lesser curvature of the stomach and the abdominal esophagus; b - the lesser curvature of the stomach is skeletonized with preservation of the antral branches of the vagus nerve (Latarget's nerve); c - the deserotonized part of the lesser curvature of the stomach is peritonized.

the most vulnerable part of the stomach adjacent to the antrum, where ulcers of types I and P are most often localized according to N. Johnson [Kovalchuk L. A., 1988] (Fig. 4).

M. I. Kuzin et al. (1980) proposed the so-called extended selective proximal vagotomy, the essence of which is that in addition to the intersection of the branches of the vagus nerves going to the acid-forming part of the stomach from the lesser curvature, the greater curvature of the stomach is mobilized, starting 4-5 cm from the pylorus and to the level of the lower pole of the spleen with the intersection of both gastroepiploic and 1-2 short arteries of the stomach (Fig. 5). Thanks to this improvement, the authors were able to reduce the rate of incomplete vagotomy from 23 to 6%. The authors believe that the effect of extended selective proximal vagotomy is enhanced by the intersection of the branches of the vagus nerves going to the stomach from the greater curvature together with the gastroepiploic vessels. However, here it is necessary

Rice. 4. Scheme of proximal selective vagotomy in combination with segmental resection of the stomach (according to L. A. Kovalchuk, 1988).

a - border of gastric resection along with ulcer after vagotomy; b - view after the formation of the gastric anastomosis.

We should recall the work of L. Z. Frank-Kamenetsky (1948) from the Moscow clinic of V. S. Levit, in which it was proven that when mobilizing the greater curvature of the stomach with the intersection of the gastroepiploic arteries, partial desympatization of the stomach occurs, as a result of which a decrease in the production of free hydrochloric acid and the motor-evacuation function of the stomach is enhanced. Thus, the mechanism of the therapeutic effect of extended selective proximal vagotomy is more complex than when crossing the vagus nerves alone.

Rice. 5. Scheme of extended selective proximal vagotomy (according to M.I. Kuzin et al., 1980).

a - skeleton of the lesser curvature of the stomach and abdominal esophagus with preservation of the Latarget nerves; mobilization of the greater curvature of the stomach by cutting the gastrocolic ligament; b - permtonic area of ​​the lesser curvature of the stomach and esophagus, the suture of the gastro-occipital ligament to the stomach.

At the end of the 70s of our century, prof. T. Taylor from Edinburgh (1976) developed a new type of selective proximal vagotomy, which he called superficial seromyotomy of the lesser curvature of the stomach. The author considered the anatomical basis of the operation to be that the gastric branches of the vagus nerves, before they are introduced into muscle layer stomach pass for 2-3 cm under serosa separately from the blood vessels and at a more acute angle, and only after that they are immersed in the muscular layer of the gastric wall. Parasympathetic denervation of the stomach with this intervention is achieved by dissecting the serous and muscle layers its anterior and posterior walls at a distance of 1-1.5 cm from the edge of the lesser curvature and parallel to it from the proximal border of the antrum of the stomach (angle of the stomach) to the angle of His. In this case, the gastric branches of the vagus nerve are crossed. The largest vessels remain intact, since they pass mainly between the anterior and posterior serous layers of the lesser omentum and are embedded in the pars nuda of the lesser curvature of the stomach in its most convex part. Small and superficial vessels are ligated along the incision. The integrity of the gastric mucosa is checked at the end of the operation by introducing air into the stomach. The author does not apply sutures to the edges of the incision of the seromuscular layer of the stomach, i.e., he proceeds as is done during pyloromyotomy in newborns (Ramstedt, 1912] or myotomy of the esophagus according to Heller (1913) for cardiospasm (Fig. 6). in the wall of the stomach there is a “groove” up to 1.5-2 cm The author considers it an insurmountable obstacle to the germination of the crossed branches of the vagus nerve. In this case, necrosis of the stomach wall does not occur, since its blood supply is slightly disturbed. Damage to the Latarget nerves is also eliminated, and normal function of the pyloric muscle is preserved, making drainage surgery unnecessary.

Rice. 6. Scheme of anterior seromyotomy of the body and fundus of the stomach in combination with posterior truncal vagotomy (arrow). Explanation in the text.

The experience of such operations is still small, but the first results, according to the author of the intervention, are favorable. True, Prof. himself T. Taylor, judging by his latest works (Taylor T. etal., 1985; 1988], modified the operation and now, unlike the original version, combines anterior seromyotomy of the lesser curvature of the stomach with posterior truncal vagotomy. In this case, an unloading operation is also not performed , and the authors did not observe any sharp disturbances in the evacuation function of the stomach. Other authors also adhere to this modified version of seromyotomy, but some of them, unlike the founder of seromyotomy, sutured the edges of the dissected seromuscular layer of the stomach wall [Petrov V.I. et al., 1988]. With further study of the topographic anatomy of vessels and nerves in the area of ​​the lesser curvature of the stomach in relation to selective proximal vagotomy, it was established that with “primordial” seromyotomy, some gastric branches of the vagus nerve cannot be crossed, since they are embedded in the parsnuda of the lesser curvature of the stomach and when dissecting the serous leaves do not fall into the cut zone [Ivanov N. N., 1989; Petropoulos P., 1981]. Histological and pH-metric studies show that parasympathetic innervation and active acid production are preserved along the lesser curvature in the gastric mucosa after such an operation. These studies were the basis for the so-called extended seromyotomy, unfortunately called transgastric selective proximal vagotomy. The prefix “trans” is usually associated with manipulations from the lumen of the organ, and not from its outer cover.

The extended seromyotomy technique [Gorbashko A.I., Ivanov N.N., 1988] includes mobilization of the greater curvature of the stomach with the intersection of both gastroepiploic arteries, the fundus of the stomach and the abdominal esophagus, dissection of the seromuscular layer along the lesser curvature of the stomach, as is done with conventional seromyotomy. Next, the seromuscular layer is dissected away from the submucosal layer towards the parsnudae, preserving the vessels leading to it. Nerve branches cross. The operation is completed by applying seromuscular sutures to the skeletonized part of the lesser curvature of the stomach (Fig. 7).

There is still no significant experience of such operations and their long-term results. We can only say that there is a continuous search for ways to increase the effectiveness of vagotomy. In conclusion, I would like to warn young surgeons against an imprudent enthusiasm for vagotomy techniques that have just appeared and have not yet been tested by experience.

Rice. 7. Scheme of extended selective proximal vagotomy according to A. I. Gorbashko and N. N. Ivanov (1988).

a - mobilization of the greater curvature of the stomach with the intersection of the right (1) and left

(2) gastroepiploic arteries; mobilization of the fundus of the stomach and abdominal esophagus with release of the anterior

(3) and posterior (4) vagus nerves;

dissection of the seromuscular layer of the lesser curvature of the stomach (6) with preservation of the Latarget nerve: b - preparation of the seromuscular layer in the area of ​​the lesser curvature of the stomach with preservation of the vessels leading to it (5, 7); c - suturing of the defect of the serous-muscular layer (6), peritonization of the skeletal area of ​​the lesser curvature of the stomach, fundoplication; a similar operation is performed on the back wall of the stomach.