Where is your vagotomy incomplete? Observations on operative technique

There is a trend in gastric surgery towards more selective types of vagotomy but the techniques are more difficult and incomplete nerve section may be more likely. Using the Grassi intra-operative test of mucosal pH, we have studied 50 consecutive patients, 13 having truncal vagotomy, 9 having bilateral selective vagotomy and 28 having proximal gastric vagotomy. We have identified four distinct areas of the stomach where nerve fibres are likely to be left. Three of these can usually be eliminated by careful attention to technique, but the fourth--the distal extent of the parietalcell mass--can only be identified by a precise intra-operative test; this is relevant to proximal gastric vagotomy but not to truncal vagotomy. Unexpected anatomical variations of the vagus nerve branches were found in 8 patients. A precise intra-operative test of residual innervation is particularly helpful in establishing the technique of proximal gastric vagotomy.