Robotic Thoracic Truncal Vagotomy

Patient Selection 

The main indication for thoracic truncal vagotomy is recalcitrant marginal ulcer following previous gastric surgery (1,2). This procedure helps reduce gastric acid production, promoting ulcer healing and preventing further complications. Patients who experience persistent or recurrent ulcers despite prior interventions such as proton pump inhibitors or surgical procedures may benefit from this approach. This technique has been proven effective in approximately 70-85 percent of patients with marginal ulcers (3). Possible secondary effects including gastric motility issues such as delayed gastric emptying or gastroparesis, and changes in bowel habits must be communicated to patients. There may also be an increased risk of diarrhea due to changes in gastrointestinal function. 
The robotic approach offers a minimally invasive option, providing greater precision and reduced recovery time compared to traditional open surgery. This makes it an ideal choice for patients requiring effective long-term management of their ulcer disease. 
 
Operative Steps 

 1.) Preparation 

General anesthesia was administered, and the patient was intubated with a selective left double-lumen endotracheal tube. The patient was positioned in the left lateral decubitus position. A peripheral intravenous line, arterial line, orogastric tube, defibrillation pads, sequential compression devices, and pressure-point padding were applied. The chest was prepped and draped in the standard sterile technique. 

 2.) Surgical Approach 

Three 8 mm robotic ports were placed on the right hemithorax: the posterior port and camera port at the level of the eighth intercostal space, and the anterior port at the level of the seventh intercostal space. Additionally, a 12 mm assistant port was inserted at the level of the ninth intercostal space. The da Vinci robotic system was docked and connected to the robotic arms. 

3.) Field Exposure and Bilateral Truncal Vagotomy 

The procedure commenced with division of the inferior pulmonary ligament, starting from the diaphragm and extending to the inferior pulmonary vein. Then, the posterior mediastinal pleura was carefully opened to expose the distal thoracic esophagus. The right vagus nerve was identified and meticulously dissected. Subsequently, the posterior aspect of the esophagus was exposed, and the esophagus was encircled with a vessel loop. After applying traction, the posterior portion of the esophagus was further exposed, allowing for identification and dissection of the left vagus nerve. Both vagus nerves were then independently clipped and transected. 

After ensuring hemostasis, intercostal local anesthetics were infiltrated. The lung was properly expanded. A 20 French chest drain was placed and secured to the skin with silk sutures. The incisions were closed, and sterile dressings were applied. 
 
Tips and Pitfalls 

Tips 

The surgeons recommend transecting both vagus nerves at the most distal level possible in the thoracic region, close to the diaphragm. This approach helps preserve the posterior bronchial branches of the vagus nerve, which can be important for maintaining normal bronchial tone. Cutting these bronchial branches may lead to bronchodilation, reduced mucus secretion, and a diminished cough reflex, increasing the risk of complications such as bronchial aspiration and pneumonia. 

Caveats 

One important precaution during the procedure is to perform a gentle and careful dissection near the thoracic duct to avoid injury. Damage to the thoracic duct can lead to postoperative chylothorax. Proper dissection techniques and awareness of the thoracic duct's location are essential to minimize this risk. 

Another important precaution is to avoid damaging the esophagus during its dissection. To assist in the dissection and manipulation of the esophagus, the placement of a nasogastric tube can be beneficial. The tube helps stabilize and gently retract the esophagus, reducing the risk of inadvertent injury during the procedure. If there is any doubt regarding potential damage to the esophagus, an intraoperative esophagogastroduodenoscopy (EGD) can be performed to assess the integrity of the esophagus and ensure no injury has occurred. 
Care must also be taken when working near the aorta and the azygos vein. These structures are in close proximity to the area of dissection and can be injured. Thorough dissection and careful retraction of surrounding tissues are essential to avoid inadvertent injury to these important vascular structures. 

References

1. Gullà P, Tassi A, Cirocchi R, Longaroni M. Thoracoscopic truncal vagotomy. J Cardiovasc Surg (Torino). 2000 Dec;41(6):941-3. PMID: 11232981.
2. Avtan L, Avci C, Arici C, Berber E. Video thoracoscopic truncal vagotomies: technique and preliminary results. Hepatogastroenterology. 1996 Nov-Dec;43(12):1689-94. PMID: 8975990.
3. Yu LJ, Maxfield MW, Chow OS, Whyte RI, Wilson JL, Kent MS, Gangadharan SP. Video- and Robotic-Assisted Thoracoscopic Truncal Vagotomy. Am Surg. 2023 Jun;89(6):2955-2959.

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