Annals of the Royal College of Surgeons of England (1990) vol. 72, 9-10
selective vagotomy: use of a ligature carrier Highly
Derek J Byrne
MB FRCSI*
Registrar in Surgery
W A F McAdam FRCSEd & Glas Consultant Surgeon
Airedale General Hospital, West Yorkshire
Key words: Vagotomy; Surgical instruments; Surgical equipment
A ligature carrier for use in tying the neurovascular bundle along the lesser curve of the stomach during highly selective vagotomy is described. This is presented as a safe and efficient way of performing this part of the operation.
Highly selective vagotomy (HSV) is now regarded by many as the operation of choice for uncomplicated duodenal ulcer (1-3). A series of 312 HSVs have been performed at this hospital by one surgeon (WAFM) since 1971, and the overall operative technique and results have been described elsewhere (4). Over the years the use of a ligature carrier, described below, has increased the efficiency and the safety of the operation. The original carrier was made from a Lister's urethral sound with the curve slightly straightened and a Dunhill metal ligature holder, brazed to the sound by our hospital engineer, Phil Bandha (Fig. lb). Because the sound was made of such hard metal and was impossible to drill, small nodules were brazed onto the tip and the bend of the instrument, and then drilled to take the ligature material (Fig. 2). In the late 1970s and early 1980s Down Brothers of London produced a prototype instrument which has been used over the years and is a very satisfactory instrument indeed (Fig. la). Recently, with the production of linen on a plastic carrier by Ethicon®, the handle of the instrument has been modified to take one of these spools by our late friend Fritz Lietzke (Fig. lc). Our purpose in describing the history of the instruPresent appointment: Research Fellow, Department of Surgery, Ninewells Hospital and Medical School, Dundee Correspondence to: Mr W A F McAdam, Consultant Surgeon, Airedale General Hospital, Steeton, Keighley, West Yorkshire
ment is to show that any surgeon with a friendly engineer can produce a ligature carrier of this style, the design of which was originally conceived by the collaboration of our Theatre Superintendent, Miss Mary Scanlon and the senior author. In Airedale we call it the Scanlon/ McAdam ligature carrier.
Technique The ligature carrier is based on previous ligature carriers described in the literature (5-7). It is used as follows: 1 The peritoneum over the lesser curve is divided with scissors. This makes subsequent ligation of the
*
BD20 6TD
Figure 1. The heads of the three modifications of the instrument are shown. (a) Down Brothers prototype. (b) Lister's sound and Dunhill ligature holder. (c) Most recent model loaded with an Ethicon plastic ligature holder.
10
D J Byrne and W A F McAdam nerves of Latarjet if the bleeding is coming from the right side of the neurovascular bundle. The method we describe does not have the disadvantages outlined above, and the ligature carrier has advantages over the aneurysm needle. Its shape makes it comfortable to use, particularly in deep wounds, and it provides a continuous feed of suture material from a spool (Fig. 1c) that can be changed in seconds. This obviates the need for repeated threading of an aneurysm needle and eliminates tedium when many knots have to be tied. We are not aware of any other ligature carrier of the shape and reach of this instrument, which we find invaluable when working high up behind the oesophagus. The slender Lister's sound, on which this instrument is based, has a pleasing spring about it when a knot is tied that makes the instrument a pleasure to use.
Figure 2. Representation of technique of tying neurovascular bundles.
References neurovascular bundles easier, as a surprising amount of force is sometimes needed to push an instrument through the serosa (8,9). 2 The neurovascular bundle to be tied is isolated with a non-toothed dissecting forceps with the guide-bar ground off to prevent the thread catching on it (Fig.
2). 3 The ligature carrier, having been suitably loaded with a spool of thread, is passed under the bundle, guided by the forceps (Fig. 2). 4 A nerve hook is then used by the assistant to pull the thread through (Fig. 2). The knot is then tied using a one-handed tie with the left hand. The process is then repeated on the other side of the bundle. 5 The neurovascular bundle is then divided with scissors, again using the forceps as a guide.
Discussion A large part of the time taken in performing a HSV is spent tying off the neurovascular bundles which supply the parietal cells. Metal clips have been recommended as useful for this part of the operation (10) but, like others (11, 12), we found that as the dissection proceeds the clips are liable to catch in swabs and be pulled off. Another method of dividing the neurovascular bundles is by placing an artery forceps on each side and dividing and tying each bundle. However, vessels can slip out or be pulled out from these forceps, resulting in haemorrhage. These vessels can retract into the fat, thus making haemostasis difficult with the added risk of damaging the
1 Enskog L, Rydberg B, Adami HO, Enander LK, Ingvar C. Clinical results 1-10 years after highly selective vagotomy in 306 patients with prepyloric and duodenal ulcer disease. Br J Surg 1986;73:357-60. 2 Rossi RL, Dial PF, Georgi B, Braasch JW, Shea JA. A five to ten year follow-up study of parietal cell vagotomy. Surg Gynecol Obstet 1986;162:301-6. 3 Van Holstein C, Graffner H, Oscarson J. One hundred patients ten years after parietal cell vagotomy. Br J Surg 1987;74: 101-3. 4 Byrne DJ, Brock BM, Morgan AG, McAdam WAF. Highly selective vagotomy; a 14 year experience. Br J Surg 1988;75:869-72. 5 Tibbs DJ. A continuous-feed aneurysm needle. Br Med 7 1952;2: 1201. 6 Dowling BL. Fine continuous-feed aneurysm needle. Br MedJ' 1970;2:677. 7 Tinckler L. A universal ligature applicator. Med J Aust 1971;2:961-2. 8 Amdrup E, Jensen HE. Selective vagotomy of the parietal cell mass preserving innervation of the undrained antrum. Gastroenterology 1970;59:522-7. 9 Johnson D. Peptic ulceration: highly selective vagotomy. In: Keen G ed. Operative Surgery and Management. Bristol: Wright, 1981. 10 Salaman JR. Highly selective vagotomy using Tantalum clips. Br J Surg 1978;65:155-6. 11 Goligher JC. A technique for highly selective (parietal cell or proximal gastric) vagotomy for duodenal ulcer. BrJ Surg 1974;61:337-45. 12 Wood JJ, Ryan JM, Anders CJ. Proximal gastric vagotomy: a district general hospital experience. Ann R Coll Surg Engl 1983;65: 185-7. Received 24 May 1989
selective vagotomy: use of a ligature carrier Highly
Derek J Byrne
MB FRCSI*
Registrar in Surgery
W A F McAdam FRCSEd & Glas Consultant Surgeon
Airedale General Hospital, West Yorkshire
Key words: Vagotomy; Surgical instruments; Surgical equipment
A ligature carrier for use in tying the neurovascular bundle along the lesser curve of the stomach during highly selective vagotomy is described. This is presented as a safe and efficient way of performing this part of the operation.
Highly selective vagotomy (HSV) is now regarded by many as the operation of choice for uncomplicated duodenal ulcer (1-3). A series of 312 HSVs have been performed at this hospital by one surgeon (WAFM) since 1971, and the overall operative technique and results have been described elsewhere (4). Over the years the use of a ligature carrier, described below, has increased the efficiency and the safety of the operation. The original carrier was made from a Lister's urethral sound with the curve slightly straightened and a Dunhill metal ligature holder, brazed to the sound by our hospital engineer, Phil Bandha (Fig. lb). Because the sound was made of such hard metal and was impossible to drill, small nodules were brazed onto the tip and the bend of the instrument, and then drilled to take the ligature material (Fig. 2). In the late 1970s and early 1980s Down Brothers of London produced a prototype instrument which has been used over the years and is a very satisfactory instrument indeed (Fig. la). Recently, with the production of linen on a plastic carrier by Ethicon®, the handle of the instrument has been modified to take one of these spools by our late friend Fritz Lietzke (Fig. lc). Our purpose in describing the history of the instruPresent appointment: Research Fellow, Department of Surgery, Ninewells Hospital and Medical School, Dundee Correspondence to: Mr W A F McAdam, Consultant Surgeon, Airedale General Hospital, Steeton, Keighley, West Yorkshire
ment is to show that any surgeon with a friendly engineer can produce a ligature carrier of this style, the design of which was originally conceived by the collaboration of our Theatre Superintendent, Miss Mary Scanlon and the senior author. In Airedale we call it the Scanlon/ McAdam ligature carrier.
Technique The ligature carrier is based on previous ligature carriers described in the literature (5-7). It is used as follows: 1 The peritoneum over the lesser curve is divided with scissors. This makes subsequent ligation of the
*
BD20 6TD
Figure 1. The heads of the three modifications of the instrument are shown. (a) Down Brothers prototype. (b) Lister's sound and Dunhill ligature holder. (c) Most recent model loaded with an Ethicon plastic ligature holder.
10
D J Byrne and W A F McAdam nerves of Latarjet if the bleeding is coming from the right side of the neurovascular bundle. The method we describe does not have the disadvantages outlined above, and the ligature carrier has advantages over the aneurysm needle. Its shape makes it comfortable to use, particularly in deep wounds, and it provides a continuous feed of suture material from a spool (Fig. 1c) that can be changed in seconds. This obviates the need for repeated threading of an aneurysm needle and eliminates tedium when many knots have to be tied. We are not aware of any other ligature carrier of the shape and reach of this instrument, which we find invaluable when working high up behind the oesophagus. The slender Lister's sound, on which this instrument is based, has a pleasing spring about it when a knot is tied that makes the instrument a pleasure to use.
Figure 2. Representation of technique of tying neurovascular bundles.
References neurovascular bundles easier, as a surprising amount of force is sometimes needed to push an instrument through the serosa (8,9). 2 The neurovascular bundle to be tied is isolated with a non-toothed dissecting forceps with the guide-bar ground off to prevent the thread catching on it (Fig.
2). 3 The ligature carrier, having been suitably loaded with a spool of thread, is passed under the bundle, guided by the forceps (Fig. 2). 4 A nerve hook is then used by the assistant to pull the thread through (Fig. 2). The knot is then tied using a one-handed tie with the left hand. The process is then repeated on the other side of the bundle. 5 The neurovascular bundle is then divided with scissors, again using the forceps as a guide.
Discussion A large part of the time taken in performing a HSV is spent tying off the neurovascular bundles which supply the parietal cells. Metal clips have been recommended as useful for this part of the operation (10) but, like others (11, 12), we found that as the dissection proceeds the clips are liable to catch in swabs and be pulled off. Another method of dividing the neurovascular bundles is by placing an artery forceps on each side and dividing and tying each bundle. However, vessels can slip out or be pulled out from these forceps, resulting in haemorrhage. These vessels can retract into the fat, thus making haemostasis difficult with the added risk of damaging the
1 Enskog L, Rydberg B, Adami HO, Enander LK, Ingvar C. Clinical results 1-10 years after highly selective vagotomy in 306 patients with prepyloric and duodenal ulcer disease. Br J Surg 1986;73:357-60. 2 Rossi RL, Dial PF, Georgi B, Braasch JW, Shea JA. A five to ten year follow-up study of parietal cell vagotomy. Surg Gynecol Obstet 1986;162:301-6. 3 Van Holstein C, Graffner H, Oscarson J. One hundred patients ten years after parietal cell vagotomy. Br J Surg 1987;74: 101-3. 4 Byrne DJ, Brock BM, Morgan AG, McAdam WAF. Highly selective vagotomy; a 14 year experience. Br J Surg 1988;75:869-72. 5 Tibbs DJ. A continuous-feed aneurysm needle. Br Med 7 1952;2: 1201. 6 Dowling BL. Fine continuous-feed aneurysm needle. Br MedJ' 1970;2:677. 7 Tinckler L. A universal ligature applicator. Med J Aust 1971;2:961-2. 8 Amdrup E, Jensen HE. Selective vagotomy of the parietal cell mass preserving innervation of the undrained antrum. Gastroenterology 1970;59:522-7. 9 Johnson D. Peptic ulceration: highly selective vagotomy. In: Keen G ed. Operative Surgery and Management. Bristol: Wright, 1981. 10 Salaman JR. Highly selective vagotomy using Tantalum clips. Br J Surg 1978;65:155-6. 11 Goligher JC. A technique for highly selective (parietal cell or proximal gastric) vagotomy for duodenal ulcer. BrJ Surg 1974;61:337-45. 12 Wood JJ, Ryan JM, Anders CJ. Proximal gastric vagotomy: a district general hospital experience. Ann R Coll Surg Engl 1983;65: 185-7. Received 24 May 1989
