Surgical workshop Br. J. Surg. 1992, Vol. 79, March, 254
Thoracoscopic vagotomy: a new use for the laparoscope E. M. Chisholm, S. C. S. Chung, G. T. Sunderland, H. T. Leong and A. K. C. Li Department of Surgery, Prince of Wales Hospital, Chinese University gf Hong Kong, Shatin, Hong Kong Correspondence to: Professor A. K. C.Li
The management of recurrent ulceration after previous gastric operations is a problem for both gastroenterologist and surgeon. Lesions that fail primary surgical treatment are often refractory to medical treatment'. The potential complications of recurrent ulceration bring considerable pressure to perform another operation. Further abdominal intervention is associated with considerable morbidity, a reported mortality rate of between 4 and 20 per cent and an ulcer re-recurrence rate of 10-20 per Transthoracic vagotomy has been advocated in the management of patients with stomal ulcers or where incomplete vagotomy is suspected, to reduce acid production and to promote ulcer healing5. The advantage of such an approach is the opportunity to work in an undisturbed operative field, which makes complete vagotomy more likely to be achieved than by a further abdominal approach5. A report of a patient with stomal ulceration who underwent transthoracic vagotomy using an endoscopic technique is presented.
Technique A 58-year-old man underwent a two-thirds Polya gastrectomy in 1986 for recurrent haematemesis and melaena from a gastric ulcer. In 1988, he experienced intermittent dyspepsia and at endoscopy was found to have a stomal ulcer. He was referred to this hospital in December 1990 after repeated coffee ground vomiting despite H,-receptor antagonist therapy. He was treated with omeprazole (Losec, Astra, King's Langley, UK ) and sucralfate (Ulsanic, Chugai Pharmaceutical, Tokyo, Japan ) after further endoscopy demonstrated a 2-cm stomal ulcer and haemorrhagic gastritis. The ulcer showed signs of healing at 6 weeks but the patient was still symptomatic. In view of the complication of repeated bleeding it was felt that a truncal vagotomy was indicated. His general condition and previous abdominal surgery suggested transthoracic truncal vagotomy as the appropriate approach, and an endoscopic technique was used. Under general anaesthesia the patient was placed in the right lateral position. A double lumen endotracheal tube was employed to permit collapse of the left lung. A 10-mm trocar and cannula was inserted through the eighth intercostal space in the posterior axillary line and the laparoscope was introduced. Carbon dioxide insufflation was not used during the procedure. Three further 5-mm ports were then established in the sixth, eighth and tenth intercostal spaces, in the mid-axillary line. This allowed dissection of the oesophagus, retraction of the lung and retraction of the diaphragm. The inferior pulmonary ligament was freed, and the lung was retracted cephalad. The space behind the pericardiacophrenic junction medial to the aorta was opened and the oesophagus was identified. The vagal trunks were identified and clipped with titanium staples, and a portion of each was excised for frozen histological section. The oesophagus could be manipulated using grasping forceps, and the whole circumference could be visualized to identify any further nerve fibres. O n confirmation of nerve bundles on frozen section in the specimens an intercostal drain was inserted via a porthole and manipulated into position under vision. The operation lasted 3 h. The patient was able to eat normally 4 h after operation, and required only one intramuscular injection of analgesic. The chest drain was removed on day 2 and he was discharged on the third day after operation. Endoscopy 3 months after the procedure showed that the ulcer had healed.
Discussion Laparoscopic cholecystectomy demonstrates the principle of using minimally invasive techniques to perform standard surgical procedures. This technique leaves the patient with barely perceptible scars, and allows prompt discharge from hospital and early resumption of work6. With the introduction of laparoscopic hernia repair and appendicectomy, the range of endoscopic procedures is increasing7. Variations of highly selective vagotomy have been performed laparoscopically', but the procedure is tedious and time-consuming. Open thoracotomy for transthoracic vagotomy may be safer than transabdominal re-exploration of the lower oesophagus. It could not be described as minimally invasive. Operative thoracoscopy is not new ; transthoracic endoscopic ablation of the sympathetic chain is one of the standard procedures for hyperhidrosis of the upper limb'. Experience with laparoscopic cholecystectomy and considerable oesophageal surgical exper1 led us to believe that transthoracic endoscopic truncal vagotomy could be performed safely. The oesophagus is identified by working with forceps in an anteromedial direction towards the base of the pericardium at the cardiacophrenic border. Once in the plane of the oesophagus the nerve fibres can easily be isolated. The procedure is less demanding than laparoscopic cholecystecomy. Any surgeon trained and competent in laparoscopic cholecystectomy could perform this procedure endoscopically. Owing to the minimal distress caused to the patient by the procedure, he was discharged on the third day after operation. The average hospital stay5 in one series of 47 patients for operative thoracotomy and thoracic vagotomy was 11 days. Abdominal re-exploration may require an even longer hospital stay. Where there is no active intra-abdominal complication of recurrent peptic ulceration, which would necessitate an abdominal approach, transthoracic endoscopic ablation of the vagal trunks is justified. The potential for minimal surgical trauma to patients, often at risk for their general condition, gives this latest vagotomy procedure an obvious advantage. It may find a role in the management of recurrent peptic ulceration, particularly after gastrectomy, where truncal vagotomy would be beneficial.
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Paper accepted 27 September 1991
1992 Butterworth-Heinemann Ltd