A vagotomy is a surgical procedure that involves the cutting or removal of a portion of the vagus nerve. This nerve, also known as the tenth cranial nerve, extends from the brainstem down to the abdomen and plays a major role in the parasympathetic nervous system. Its function includes regulating the activity of several internal organs, particularly in the digestive tract. The primary purpose of performing a vagotomy is to interrupt the nerve signals that stimulate the stomach to produce acid. By severing these fibers, surgeons can significantly reduce the volume and acidity of gastric secretions.
Medical Conditions Treated
Historically, the vagotomy procedure was a common intervention for severe cases of peptic ulcer disease, which includes ulcers in both the stomach and the duodenum. The vagus nerve stimulates parietal cells to release hydrochloric acid, primarily through the neurotransmitter acetylcholine. Interrupting this pathway surgically was an effective method to lower the acid levels irritating the ulcerated lining.
This procedure was once considered the standard treatment for ulcers that were chronic, recurrent, or complicated by bleeding or perforation. The need for surgical intervention has significantly decreased since the widespread adoption of effective medications, such as H2-receptor antagonists and proton pump inhibitors. These drugs offer excellent control over acid secretion and, along with antibiotics to treat Helicobacter pylori infection, have largely replaced elective vagotomy.
While less common today, vagotomy remains an option for patients with refractory ulcers that fail to heal despite maximum medical therapy. It is also sometimes performed in emergency settings for conditions like severe gastrointestinal bleeding or when an ulcer causes a blockage at the stomach outlet. Its established role remains tied to managing excessive gastric acidity.
Types of Vagotomy Procedures
Vagotomy procedures are categorized based on how much of the vagus nerve is severed. The most extensive type is the Truncal Vagotomy, which involves cutting the main trunks of the vagus nerve where they enter the abdomen, typically near the esophagus. This method achieves the greatest reduction in acid but interrupts all nerve signals to the entire stomach, liver, gallbladder, and intestines.
A slightly more precise approach is the Selective Vagotomy, where the surgeon severs only the vagal branches that supply the stomach. The branches that continue to the liver, gallbladder, and intestines are preserved. However, both truncal and selective vagotomies still denervate the muscles controlling the pylorus, the valve that regulates the emptying of the stomach.
The most targeted procedure is the Highly Selective Vagotomy, also called a parietal cell vagotomy. This technique involves cutting only the small nerve branches that supply the acid-producing parietal cells in the upper stomach body and fundus. The nerves that control the antrum and the pylorus are left intact. By preserving the nerve function of the pylorus, this technique aims to avoid the gastric motility issues seen with the other types.
Managing Digestive System Changes
Severing the vagus nerve disrupts not only acid production but also the nerve signals that regulate gastric motility, the muscular contractions that move food through the digestive tract. This loss of motor function, particularly affecting the pyloric sphincter, can lead to a condition called gastric stasis, where food remains in the stomach for too long. For this reason, a Truncal or Selective Vagotomy must be accompanied by a drainage procedure to ensure the stomach can empty properly.
The most common drainage procedure is a pyloroplasty, which involves surgically widening the pyloric valve to allow food to pass more easily into the small intestine. This bypasses the need for the nerve-controlled muscular relaxation that the vagotomy has eliminated. Alternatively, a surgeon may perform a gastrojejunostomy, which creates a new direct connection between the stomach and the middle section of the small intestine.
Altering the stomach’s emptying mechanism can also result in post-operative complications like dumping syndrome. This condition occurs when the stomach empties its contents too rapidly into the small intestine, leading to symptoms such as abdominal cramping, diarrhea, and dizziness shortly after eating. Managing these physiological changes often requires long-term dietary adjustments, such as eating smaller, more frequent meals, and limiting the intake of liquids and simple sugars with meals.