Vagotomy during hiatal hernia repair: a benign esophageal lengthening procedure

This study describes the use of vagotomy in patients during complex laparoscopic esophageal surgery (e.g., reoperative antireflux surgery (rLARS) or paraesophageal hernia (PEH) repair) when, after extensive esophageal mobilization, the gastroesophageal junction cannot be made to reach the abdomen without tension. In doing so, we hope to understand the risk incurred by vagus nerve division in this setting in order to evaluate its role in managing the short esophagus.

One hundred and sixty-six patients underwent rLARS or PEH repair between 1/1998 and 6/2003 at our institution. Clinical data was obtained from a prospectively maintained database and systematic patient questionnaires administered for this study. Follow-up was available for 102 (61%) of these patients, at a median of 19 months (range 6-69 months).

Fifty-two patients underwent rLARS while 50 patients underwent PEH repair. Thirty patients had a vagotomy during the course of their operation (Vag Group; 20 anterior, six posterior, four bilateral), 13 in the rLARS group (25%), and 17 in the PEH group (34%). The primary presenting symptoms for rLARS and PEH repair patients were improved in 89% in the Vag Group and 91% in the No Vag Group. Similarly, there was no difference in the severity of abdominal pain, bloating, diarrhea, or early satiety between the Vag and No Vag groups at follow-up. No patient required a subsequent operation for gastric outlet obstruction.

Vagotomy during rLARS and PEH repair does not lead to a higher rate delayed gastric emptying, dumping syndrome, or other side effects. Thus, we propose vagotomy to be a legitimate alternative to Collis gastroplasty when extensive mobilization of the esophagus fails to provide adequate esophageal length.