Laparoscopic Vagotomy Research Articles

Laparoscopic management of benign gastric outlet obstruction: a case series with review of literature

Surgery for peptic ulcer disease has since long become a thing of the past, in the era of proton pump inhibitors. Today, it is difficult to believe that these were common operations about 6-7 decades ago. Such has been the impact of proton pump inhibitors (PPI), that, surgery for peptic ulcer has been relegated to the realms of history. However, even in present day, in some rare clinical situations, surgeons may have to resort to surgery for patients suffering from peptic ulcer disease. Herein, we present our experience of laparoscopic surgical management of one of those rare clinical scenarios related to severe peptic ulcer disease. The clinical condition in discussion is gastric outlet obstruction caused by severe peptic ulcer disease in the first part of duodenum. We identified 8 patients (7 males and 1 female) who underwent laparoscopic vagotomy with gastrojejunostomy for benign gastric outlet obstruction, at our institution, operated upon by a single surgeon, between 2004 to 2023. All patients had undergone oesophago-gastro-duodenoscopy (OGD scopy), and contrast enhanced computerised tomography (CECT) of the abdomen. The patients were analysed for age, sex, symptoms, pre-operative evaluation, morbidity/mortality and functional outcomes. They were also reviewed to examine the length of stay, length of procedure, complications and recurrent symptoms on follow-up.

Role of Vagal Fibers in Weight Control and Nutrient Absorption

Role of Vagal Fibers in Weight Control and Nutrient Absorption

Laparoscopic vagotomy using mini-instruments in the rat: a new laparoscopic small animal model.

Animal models are necessary for research, technical developments, and training purposes in laparoscopic surgery. Although various operations on small animals have been described, there is still a need for a simple and practical laparoscopic small animal model. We acknowledged truncal vagotomy as a simple procedure, and aimed to develop a model of laparoscopic truncal vagotomy (LTV) in the rat, an inexpensive and easily available animal. Fifty Wistar rats were randomized into an LTV group (n = 25) and an open truncal vagotomy (OTV) group (n = 25). LTV was effected with two minitrocars inserted into the left upper and right lower quadrants. Two techniques of vagotomy were developed: first, with the esophagus in its anatomical position, and second, with the distal esophagus retracted anteriorly with a grasper inserted into the retroesophageal space. OTV was performed through a midline incision. Animals were sacrificed 24h postoperatively, and autopsy was performed. The mean +/- SD operating time was 8.3+/-1.4 min in the LTV group and 5.5+/-0.2 min in the OTV group (P < 0.05). The laparoscopically magnified view provided a better distinction of vagal fibers compared with open surgery, with the second laparoscopic technique providing the best exposure. Complications developed in three rats (12%) from the LTV group and one (4%) from the OTV group (P > 0.05). Vagotomy was confirmed to be complete at autopsy in all of the animals. This is the first technical description of laparoscopic peptic ulcer surgery in the rat. Although subsequent histopathological and physiological studies may be required, technically, laparoscopic vagotomy in the rat seems to be a simple, inexpensive, and expeditious small-animal model for laparoscopic research.

New surgical strategy for gastroduodenal ulcer: laparoscopic approach.

Although peptic gastroduodenal ulcers are rarely treated surgically today, when surgery is required a laparoscopic approach is possible with its well known advantages. The most widely used technique is vagotomy by various modalities. Training in laparoscopy requires good instrumentation to avoid complications. Vagotomy can be truncal and bilateral via laparoscopy or thoracoscopy, which is the easiest and quickest procedure; moreover, the sequelae are less important and less frequent, as has been reported. It can also be highly selective or mixed, such as the Taylor procedure; and large series have been reported with good results. Gastric resection is rarely used for peptic ulcers, although it is feasible laparoscopically; it requires a large experience. Long-term results of laparoscopic vagotomy are now available and have indicated the same results as are attained with open surgery.

Surgical internet at a glance: Volume III

Surgical internet at a glance: Volume III

Gasless Laparoscopic Treatment of Perforated Duodenal Ulcer: A Case Report

Ruptured duodenal peptic ulcer is a serious complication of ulcer disease that occurs in approximately 5% of cases. Its emergency treatment is based on surgery, namely, simple closure or more definitive ulcer surgery. Laparoscopic repair of perforated duodenal ulcer with classic insufflation of CO2 is quick, simple, and technically feasible in most patients. We describe herein the operative treatment of a perforated duodenal ulcer in a 33-year-old man who presented to our Hospital with acute onset of severe abdominal pain. Wide peritoneal lavage and suture of the perforation was performed by gasless laparoscopic technique using a mechanical retractor obviating the creation of the pneumoperitoneum and of the sealed environment. This new approach enables the use of conventional instruments and provides a clear field of vision in the abdomen equal to that created by the traditional CO2 technique. Because there is not a pneumoperitoneum to maintain, the gasless technique permits a constant irrigation and suction of the abdominal cavity, a wide peritoneal lavage, and the continuous suction of fluid, blood, smoke, and humidity without losing the camera set. If indicated, it permits the laparoscopic repair of the perforation combined with the laparoscopic vagotomy in the same emergency setting. The present case proved it to be another abdominal procedure that can be carried out with all the technical and anesthesiological advantages of gasless minimally invasive surgery.

LAPAROSCOPIC MANAGEMENT OF PEPTIC ULCER DISEASE

Laparoscopic surgery has heralded a new era for the operative management of peptic ulcer disease. With a mean hospital stay of 3.5 days,22 a recurrence rate of 4% to 11%,1,3 and a morbidity from dumping and diarrhea of 1% to 2%,21 laparoscopic proximal gastric vagotomy can truly provide a good alternative to medical therapy. Despite the high cost of medical care and surgical equipment, a laparoscopic vagotomy should be cost effective compared with life-long pharmacologic management of peptic ulcer disease. Several different operative procedures have been discussed, with similar outcomes. The surgeon has a choice of several approaches, depending on his or her training and level of skill. As surgeons gain experience with laparoscopic surgery, we are able to offer consistently good results with low recurrence rates and negligible morbidity and mortality. Minimally invasive surgery has rekindled the operative treatment of peptic ulcer disease.

Pharyngeal Emphysema with Airway Obstruction as a Consequence of Laparoscopic Inguinal Herniorrhaphy

Pharyngeal Emphysema with Airway Obstruction as a Consequence of Laparoscopic Inguinal Herniorrhaphy

Medical Therapy Versus Laparoscopic Surgical Treatment for Ulcer Disease.

The development of low morbidity vagotomy and H2 antagonists in the early 1970s began the debate as to which was the most appropriate treatment for uncomplicated duodenal ulcer. A review of Australian Medicare and Pharmaceutical Benefits Scheme data shows that medical treatment in this country was the preferred option. In the past 12 years, vagotomies have decreased 15-fold while, in the same period, H2 antagonist prescriptions have increased from 0 to 2.5 million per year, doubling in the past 3 years, and currently costs $96 million per year or 6.7% of the country's entire pharmaceutical budget. Similarly, upper gastrointestinal tract endoscopies have increased, costing $15 million per year, doubling in the past 6 years and representing a cost almost equivalent to all other upper gastrointestinal procedures combined. Despite known efficacy and recommendations for use, triple therapy for Heliobacter species is not being used with prescriptions for surface agents actually decreasing to 40,000 per year. A review of the outcome of medical and surgical therapy shows that this expense is not justified; surgery would be more costeffective than medicine at 2 years and safer than medicine after 4 years as a result of complications from failed medical treatment. This margin of benefit is predicted to be greater with laparoscopic vagotomy. Failed medical treatment needs to be redefined by limiting H2 antagonists to a 6-week course. Recurrences or failures are than evaluated endoscopically and those diagnosed with having chronic duoderal ulcers have biopsies taken. Heliobacter pylori positive patients are treated with triple therapy. Failures, recurrences, and originally H pylori negative patients have laparoscopic vagotomy. For such a trial protocol to be evaluated, it requires the long-term use of H2 antagonists to be restricted and laparoscopic vagotomists to document the efficacy of their surgery, including gastric secretion tests.

Subcutaneous emphysema, pneumomediastinum and pneumothorax complicating laparoscopic vagotomy

Two patients developed subcutaneous emphysema and pneumomediastinum during laparoscopic vagotomy. One of the patients also had a pneumothorax which produced a sudden increase in end-tidal carbon dioxide concentration preceding arterial oxygen desaturation. The pneumothorax was drained with an intercostal cannula. The patient required a twofold increase in minute ventilation to maintain normocarbia, probably because of the additional absorption of carbon dioxide through the pleural cavity. Despite the presence of a peritoneo-pleural communication, surgery was successfully completed. We believe that gas under tension in the peritoneal cavity dissected along tissue planes around the oesophagus opened up during surgery. Thus pneumomediastinum, subcutaneous emphysema and pneumothorax are definite risks associated with this new procedure.

Laparoscopic Vagotomy

The increasing applicability of advanced laparoscopic procedures has fueled the ongoing request for the perfect ulcer operation. Using the laparoscopic approach to selectively denervate the parietal cell mass has led investigators to evaluate laparoscopic right posterior truncal vagotomy with anterior seromyotomy. The history of this procedure and its appeal to the laparoscopist is discussed. The technical aspects of the operation are outlined. Laparoscopic vagotomy may play a central role in the surgical treatment of peptic ulcer disease.

Laparoscopic vagotomy for chronic duodenal ulcer disease.

Two laparoscopic procedures for treatment of chronic duodenal ulcer are described: bilateral truncal vagotomy with balloon pyloric dilatation and posterior truncal vagotomy with anterior lesser curve seromyotomy. The first procedure is simple to perform and easily reproducible, but the latter is preferred because it respects the physiology of the stomach. Thirty-six patients were operated on over a period of 18 months with good results comparable to those with open surgery. The indications for surgery were intractable chronic duodenal ulcers resistant to optimal medical therapy. There was no perioperative morbidity or mortality, and recurrent ulcers have not been demonstrated during early postoperative follow-up. The proper role of laparoscopic surgery in the arsenal of treatment of duodenal ulcers is unclear. The method of laparoscopic vagotomy requires rigorous experimental evaluation in specialized centers before widespread clinical application. Future multicentric prospective studies with long-term follow-up are necessary to assess the results of this innovative therapy of acid-peptic disease.

Laparoscopic Vagotomy: Gimmick or Reality?

The use of H2 blockers has led to a virtual demise of elective surgery for the treatment of duodenal ulcers. Some ulcers, however, are resistant to medications, and some patients are weary of continuous medication in the long term. Laparoscopic vagotomy is a promising new form of surgical treatment that could offer an alternative to long-term medication and major open abdominal surgery. Prospective well-documented and detailed studies are needed, however, before an objective evaluation of this procedure can be made.