Background Information:

What are the other Names for the Procedure?

• Highly-Selective Vagotomy
• Selective Vagotomy
• Truncal Vagotomy

What is the Vagotomy surgical procedure?

• The vagus nerve is an extremely long nerve, extending from the stem of the brain all the way through the abdomen. It constitutes a number of branching nerves, coming into contact with the heart, lungs, voice box, stomach, ears, and a few other body parts
• The vagus nerve carries incoming information from the nervous system to the brain - information on what the body is doing. It also transmits outgoing information, which governs a range of reflex responses
• The vagus nerve has a large range of functions, which include:
  • Regulating the heartbeat
  • Transmitting a variety of chemicals throughout the body
  • It is also responsible for keeping the digestive tract in working order
  • Contracting the muscles of the stomach and intestines to help process food, and sending back information about what is being digested and what the body is getting out of it.
• The vagus nerve trunk divides into branches, in various regions of the stomach. The stimulations from all these branches result in the production and secretion of the stomach acid

Vagotomy is a surgical procedure that involves disconnection of the branches of the vagus nerve, in order to disable the production and slow down the secretion of stomach acid.

Depending upon the type of Vagotomy procedure involved, following are the other names alternatively used:

• Highly-Selective Vagotomy
• Parietal Cell Vagotomy
• Selective Vagotomy
• Truncal Vagotomy

What part of the Body does the Procedure involve?

The parts of the body involved in a Vagotomy procedure are the stomach, diaphragm, and branches of the vagus nerve.

Why is the Vagotomy surgical procedure Performed?

A Vagotomy procedure is performed as a surgical treatment for patients suffering from complications of peptic ulcers, such as:

• Perforation
• Bleeding of an ulcer
• Recurrent ulcers
• Obstruction of the digestive flow

It is carried out, when ulcers in the stomach and the duodenum (part of the intestine), do not react favorably to medicines and alterations in the diet.

What are some Alternative Choices for the Procedure?

Vagotomy is carried out, only when medications and diet alterations have no effect on the peptic ulcers. There are no other alternatives, if treatments using medicines and changes to the diet, are not helping the patient.

What are the Recent Advances in the Procedure?

There are technical developments to carry out the procedure in a less invasive way. Laparoscopy and thoracoscopy are being developed for Vagotomy.

What is the Cost of performing the Vagotomy surgical procedure?

The cost of Vagotomy procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding Vagotomy procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

http://www.laparoscopyhospital.com/vagotomy.html

http://www.mdguidelines.com/vagotomy

Prior to Vagotomy surgical procedure:

How is the Vagotomy surgical procedure Performed?

Depending on the type of surgery required - a laparotomy (open surgery), or a laparoscopy (less invasive surgery) is performed.

Laparotomy:

• A laparotomy is an open surgery, where an incision is made in the abdomen, cutting through the abdominal muscles
• The vagus nerve is then located, the specific branches are clamped and cut.

Laparoscopy:

• In case of a laparoscopy, 4-5 small incisions are made in abdomen
• A funnel shaped port is passed through one incision and carbon dioxide is administered to the inside the abdomen, which then inflates the abdomen. This allows a clearer view to the surgeon
• A laparoscope (looks like a telescope with camera and light source) is then passed into the abdomen; other surgical instruments are passed through other incisions
• The vagus nerve is located with the help of the laparoscope and using these instruments; the vagus nerve and the branches are clamped and cut

There are 4 types of surgeries performed:

• Highly Selective Vagotomy: A division of only those nerve branches, supplying the acid-secreting glands of the stomach; preservation of those supplying the antrum (distal most portion of the stomach), as well as the hepatic and celiac branches
• Parietal Cell Vagotomy: Selective severing of the nerve fibers supplying the proximal two-thirds of the stomach (parietal area; towards the intestine); carried out mostly for duodenal ulcers
• Selective Vagotomy: Division of the vagul fibres entering the stomach, with preservation of the hepatic (liver) and celiac (stomach artery) branches
• Truncal Vagotomy: The 2 main trunks of the vagus nerve entering the abdomen are disconnected

A stomach drainage procedure may be performed, to facilitate emptying of the stomach, in conditions of slowed stomach motility, caused by Vagotomy. The incisions thus made, are closed with the help of stitches or sutures.

Where is the Procedure Performed?

Vagotomy procedures are generally carried out in the surgical facility of a hospital. The average stay at the hospital is around 7 days; but, this is lesser if a laparoscopy is performed.

Who Performs the Procedure?

A general surgeon carries out a Vagotomy surgical procedure.

How long will the Procedure take?

A Vagotomy surgical procedure takes between 2-3 hours.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the surgical procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Some recent data, however suggests that carrying out the ablation procedure, while on blood thinners, reduces the risk of developing strokes
• Blood tests may be performed to determine if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Normally, local anesthesia is not used; however, do inform the physician, if you are allergic to any local anesthetics, lidocaine, etc.
• Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
• For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral

What is the Consent Process before the Procedure?

A physician will request your consent for the Vagotomy procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Vagotomy surgical procedure?

Apart from routine blood and urine tests, the following tests may need to be carried out before the Vagotomy procedure:

• EGD (esophago-gastro duodenoscopy)
• X-ray of the gastrointestinal tract
• ECG (electrocardiogram)
• CT scan of the abdomen and pelvis
• The physician may suggest further tests depending on the health of the individual and their medical history.

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are:

• What is a Vagotomy procedure?
• Why is this procedure necessary? How will it help?
• What does the procedure involve?
• Will I need adjunct treatments after the surgery?
• How soon should I get it done? Is there an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed?
• What are the risks while performing the procedure?
• What are the complications that might take place, during recovering?
• How long will it take to recover? When can I resume normal work?
• Are there any lifestyle restrictions or modifications required, after the procedure is performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• Is there any medication that needs to be taken for life, after the procedure?
• How many such procedures have you (the physician) performed?
• What are the costs involved?

During the Vagotomy surgical procedure:

What kind of Anesthesia is given, during the Procedure?

General anesthesia is given to the patient by injection, as well as through inhalation with an airway tube, placed in the windpipe.

How much Blood will you lose, during the Procedure?

The amount of blood lost depends upon the type of surgery being performed.

• If a laparotomy (open surgery) is performed, more blood may be lost, as it involves a large abdominal incision
• On the other hand, the blood loss is much lesser in case of a laparoscopy, which is a less invasive technique
• The amount of blood loss increases, in case other surgeries are combined with Vagotomy, like the stomach drainage procedure
• However, transfusions are generally not required unless any complications arise, during the procedure

What are the possible Risks and Complications during the Vagotomy surgical procedure?

There are general factors that increase the risk of getting complications during surgery and they include:

• Obesity: Generally greater the degree of obesity, greater is the surgical risk
• Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Longstanding illness, such as autoimmune disorders, chronic infections
• Poor immune system due to a variety of causes

The possible risks or complications that may arise during the surgery are:

• Injury to other veins or organs, while performing the incision
• Injury to the muscle fibers (being mistaken for the branches of the vagus nerves.)
• Excessive bleeding
• Reactions to anesthesia
• Injury to the structures/organs, adjacent to the vagus nerve (stomach, esophagus, diaphragm, pleura)

What Post-Operative Care is needed at the Healthcare Facility after the Vagotomy surgical procedure?

Nasogastric suctioning is required for few days after the surgery. The patient is kept NPO (nil per oral i.e., nothing by mouth) for a few days and the diet is gradually advanced, a few days after surgery. The patient is usually discharged home, when:

• He/she is tolerating diet
• The pain can be controlled with oral pain medications
• The patient is ambulating with minimal assistance
• He/she is able to urinate well
• Resumes bowel functions - is able to pass flatus (gas), and/or have bowel movement

After the Vagotomy surgical procedure:

What are the possible Risks and Complications after the Vagotomy surgical procedure?

Post Vagotomy procedure, the following complications may arise:

• Suture line or anastomotic leak - the suture line (anastomosis) may come apart causing leakage
• Necrosis of a portion of the stomach
• Delayed gastric emptying, because of intestinal denervation
• Dumping, because of associated pyloric disruption
• Bile reflux
• Recurrence of ulcers
• Anastomotic ulcer - formation of ulcer at the suture site
• Cholelithiasis - formation of gallstones
• Carcinoma of the stomach several years after the surgery, which is caused due to bile reflux, chronic gastritis, and intestinal metaplasia in gastric mucosa

What is the Prognosis after the Surgery?

The prognosis is good with respect to the management of peptic ulcer and its accompanying complications.

When do you need to call your Physician?

Do contact your physician if you notice any of the following symptoms:

• Pain, swelling, redness, bleeding, or drainage, in the surgical area
• Develop any signs of infection
• Headache, muscle aches, dizziness
• Feeling feverish or feeling unwell
• Nausea, diarrhea, vomiting, constipation, stools, or abdominal swelling
• Any other ‘uncomfortable’ feeling

What Post-Operative Care is needed at Home after the Vagotomy surgical procedure?

At home, the following post-operative care is recommended, after a Vagotomy procedure:

• Do not lift heavy weights for at least a month
• Take the pain-killers and anti-ulcer medicines, as prescribed by your doctor
• Diet alterations should be continued
• Often, move and keep the legs elevated, while resting, to avoid development of deep vein blood clots

How long does it normally take to fully recover, from the Procedure?

It normally takes around 6 weeks, for a complete recovery from the surgery.

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The procedure does not involve the surgical removal of any tissue.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

Since no tissue is removed during the procedure, a pathologist does not get involved in the care of the patient.

Who will you receive a Bill from, after the Vagotomy surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The outpatient facility
• A general surgeon
• An anesthesiologist (if anesthesia was administered)
• A radiologist (if radiological tests were performed during the procedure)
• Individuals are advised to inquire and confirm the type of billing, before the Vagotomy procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA