New Surgical Strategy for Gastroduodenal Ulcer: Laparoscopic Approach

World J. Surg. 24, 270–276, 2000DOI: 10.1007/s002689910044 WORLD

Journal ofSURGERY© 2000 by the Societe

Internationale de Chirurgie

New Surgical Strategy for Gastroduodenal Ulcer: Laparoscopic Approach

Francois Dubois, M.D.

Clinique Hartmann, 26 Boulevard Victor Hugo, 92200 Neuilly, France

Abstract. Although peptic gastroduodenal ulcers are rarely treated sur-gically today, when surgery is required a laparoscopic approach is possi-ble with its well known advantages. The most widely used technique isvagotomy by various modalities. Training in laparoscopy requires goodinstrumentation to avoid complications. Vagotomy can be truncal andbilateral via laparoscopy or thoracoscopy, which is the easiest and quick-est procedure; moreover, the sequelae are less important and less fre-quent, as has been reported. It can also be highly selective or mixed, suchas the Taylor procedure; and large series have been reported with goodresults. Gastric resection is rarely used for peptic ulcers, although it isfeasible laparoscopically; it requires a large experience. Long-term resultsof laparoscopic vagotomy are now available and have indicated the sameresults as are attained with open surgery.

Medical treatment of uncomplicated peptic gastroduodenal(G-D) ulcers is now so efficacious with anti-H2 agents, protonpump inhibitors (PPIs), and antibiotics against Helicopter pylorithat surgical therapy plays only a minor role. Nevertheless it is stilluseful in case of drug failure or for patients unable to undergo along and costly treatment.

The classic surgical treatment of G-D ulcers includes resectionand vagotomy, which can be done separately or in association.These procedures are feasible using a video-endoscopic approachby laparoscopy or thoracoscopy; treatment most often used isvagotomy, whatever the modality [1–3].

Techniques

The aims and modalities of laparoscopic vagotomy are the sameas for those done during open surgery.

General Requirements

Laparoscopy should be performed in an operating room by anoperator familiar with the surgical procedure because at anymoment sudden intraoperative difficulties may make it necessaryto abort the laparoscopy and convert to an open procedure. Thelaparotomy may have to be performed urgently with no time totransfer the patient to another location or to call another surgeon.The operating theater should be large enough to accommodatethe voluminous hardware needed during the procedures.

The patient should be under general anesthesia with endotra-cheal intubation to permit good ventilation during the entireprocedure. The abdominal muscles should be adequately relaxedand that state maintained to avoid sudden awakening, whichmight expose the patient to hepatic laceration from the endo-scopic instruments, as they can suddenly move out of the field ofvision. If this situation should occur, all the endoscopic instru-ments should be removed immediately until adequate relaxationis regained.

Organization of the Procedure

The patient is placed in the lithotomy position, the surgeon stand-ing between the legs of the patient with an assistant at each side(Fig. 1). Mild reverse Trendelenburg positioning is useful. Theoperating field should be large enough that the trocars can beplaced in different and unusual positions; sterile instrument pock-ets are used to store the instruments when they are not in use.

Pneumoperitoneum is created with CO2 infused through aPalmer needle in the usual manner. An intraperitoneal pressureof 12 mmHg is electronically maintained. The entire system aswell as the gas tank should be carefully checked before theprocedure is started. Standard laparoscopic instruments are used.

The trocar sites are common to all vagotomies (Fig. 2). Usuallythe endoscope is introduced via the umbilicus, or slightly above itand to the left, in a “bayonet” fashion to avoid future herniation.

Full abdominal exploration is performed first. If the duodenumcannot be well visualized because of adhesions, it is not necessaryto perform an enterolysis. A 0-degree scope is used, although a30-degree one can help visualize the esophagus, especially inobese patients. If the procedure seems feasible, the other trocarsare then inserted in the following ways: A 5-mm trocar is placedin the right flank to accommodate atraumatic forceps. A 10- or12-mm trocar is placed in the left flank for operating instruments:scissors, hook, endoclip applier, and endostapler. A 5-mm trocaris placed at the left of the xiphoid appendix for a retractor or anirrigation-suction cannula. Finally, a 5-mm trocar is placed in theleft subcostal position on the mammary line for a forceps.

The positions of the trocars vary depending on the anatomicvariations and can best be determined under direct laparoscopiccontrol. Trocars should be far apart from each other to provide amaximum range of action for each instrument and to avoid atangential approach to the organs; it is ultimately the choice of the

Correspondence to: F. Dubois, M.D., 54 Avenue de Saxe, 75015 Paris,France.

operator. In case of a left-handed operator, certain positions mustbe reversed. Finally, under direct vision, a large gastric tube(Faucher type) is inserted to unfold the stomach and betterexpose the lesser curvature. From this point on, the procedurediffers depending on the operation chosen.

Bilateral Truncal Vagotomy

Bilateral truncal vagotomy is the easiest procedure. Access to theesophagus is the same as for treatment of a hiatal hernia. First, theposterior vagus is divided (Fig. 3). The pars flaccida of the lesseromentum is then breached, two forceps or retractors are intro-duced through it, and the defect is progressively enlarged towardthe esophagus. A left hepatic artery of varying size is usuallyfound; it is not necessary to divide it.

The peritoneum is incised around the hiatus and the esophaguspushed to the left. The right crus of the diaphragm is exposed andthe peritoneum cut between it and the esophagus. The posterioraspect of the esophagus is freed until the posterior vagus islocated; it is usually bulky and easy to both recognize and free for2 to 3 cm with a hook or scissors. It is then coagulated and cut;some surgeons prefer to obtain a specimen for biopsy as proof.

Although this trunk is usually single, it is important to explorethe back of the esophagus and the front of the crus to exclude thepresence of small fibers and to divide any that are found. Theanterior vagotomy (Fig. 4) is usually simple, but it should be donecarefully to avoid vascular or mucosal injury.

Once the membrane of Laimer is incised close to the dia-phragm, the anterior aspect of the esophagus is exposed by trac-tion on the stomach, which elongates the abdominal esophagus.The anterior nerve trunk (which is usually thinner than the pos-terior nerve trunk) is identified, coagulated, and divided. One ormore accessory fibers are frequently present and must be sec-tioned. In the absence of preoperative reflux, it is not necessary toperform an antireflux procedure.

Highly Selective Vagotomy (Proximal Gastric Vagotomy)

Highly selective vagotomy (HSV) was the first vagotomy we per-formed laparoscopically in (1989) because at that time it waspractically the last kind of surgery tolerated for treatment ofuncomplicated G-D peptic ulcers. The access is the same as fortruncal vagotomy. The anterior nerve of Latarjet and the crow’sfoot is exposed by traction to the left of the stomach and use of alarge nasogastric tube. The first step is to divide the neurovascularplane on the anterior aspect of the lesser curvature (Fig. 5): Usingscissors, a diathermy hook, and a clip applicator, the three or fourneurovascular pedicles above the crow’s foot are progressively

Fig. 2. Insertion of the trocars: 1: umbilicus or upper (10 mm for thescope). 2: right subcostal (5 mm); 3: left subcostal (5 mm); 4: left flank (10mm); 5: paraxiphoid (5 mm).

Fig. 1. Patient is in the lithotomy and mild reverse Trendelenberg posi-tion. Surgeon is between the legs with one assistant on each side. Videomonitor, if possible, faces the surgeon and is fixed to the ceiling above thehead of the anesthetist.

Dubois: Gastroduodenal Ulcer Laparoscopy 271

sectioned between clips; it is important to leave stumps long enoughto avoid slippage of the clips. It is quicker to use bipolar coagulationor, even better, to have an ultrasonic (US) dissector at one’s disposal.All these steps should be carried out gently and carefully to obviatebleeding and hematoma formation, which are difficult to control,slow the operation, and possibly injure the nerve.

The dissection is carried out on the cardia up to the His angle,and the esophagus is freed on its anterior and right aspects. Theesophagus is then pushed outside, and the posterior face of thestomach is dissected as far as the omental pouch, which is entered.A forceps is placed in the hole to retract the stomach. Theposterior aspect of the esophagus is dissected far enough so at less4 cm of the esophagus freed; one must not fail to recognize thepossible Grassi’s “criminal” nerve.

The posterior neurovascular plane of the lesser curvature isthen divided downward to the level of the crow’s foot, the samemanner as for the anterior plane. In view of the high rate of laterecurrence following HSV, some surgeons extend the denervationlower on the lesser curvature, cutting one or two of the branchesof the crow’s foot. Such an HSV, with extensive mobilization ofthe cardia and esophagus (Fig. 6), creates the risk of gastroesoph-ageal reflux, which requires correction. We believe repair of theHis angle is not enough. The simplest additional procedure is tocreate an anterior valve (Dor) by attaching the fundus to the rightside of the esophagus and cardia and then to the right crus by twoor three stitches or by a running suture (Fig. 7). It is also possibleto create a posterior valve (Toupet) or even, after Cadiere, aNissen procedure, which is not our choice.

Other Types of Vagotomy (Mixed Procedures)

Because of the length and complexity of laparoscopic HSV, mixedprocedures are often used, combining a posterior truncal vagot-

omy (already described), which is easy to carry out, and anteriorgastric denervation using various techniques, previously describedfor open surgery and easily performed by laparoscopy. Hill andBarker [5] used the anterior procedure for the HSV, which is theeasiest, quickest one. Taylor [6] described anterior seromyotomy,recommended for laparoscopy by Mouiel et al. [7]. Starting at theangle of His, the incision line is outlined by light electrocoagula-tion parallel to the lesser curvature and 15 mm from it; it stops 5to 7 cm from the pylorus at the level of the crow’s foot. The mainneurovascular pedicles are clipped and divided first, and theseromyotomy is performed with the hook coagulator using mo-nopolar current. Two muscular layers are incised successively,excluding the mucosa (Fig. 8). Air is then injected through thenasogastric tube to make sure there are no leaks. The seromyo-tomy is closed by an overlapping running suture; it is also possibleto use only a fibrocollagen application. Vankemmel and Secoussesimplified the technique, performing electrodenervation on thesame line [8].

Gomez-Ferrer [9] described the anterior linear gastrectomy,removing a linear strip of the stomach’s wall, parallel to the lessercurvature (Fig. 9). Four or five shots of the endoscopic gastroin-testinal anastomosis stapler (endo-GIA) are necessary.

Postoperative Measures after Laparoscopic Vagotomy

The postoperative measures required after laparoscopic vagotomyare minimal. Antibiotic prophylaxis (cephalosporin) and heparinare given with the anesthesia premedication. Anticoagulation iscontinued during the hospital stay or longer in patients with aspecial risk of thrombosis.

The nasogastric tube is left in place for 24 hours to preventpossible acute gastric dilatation after vagotomy and to allow esti-mation of gastric acidity, a measure of the completeness of the

Fig. 3. Posterior truncal vagotomy. Fig. 4. Anterior truncal vagotomy.

272 World J. Surg. Vol. 24, No. 3, March 2000

vagotomy. A liquid diet is started after the nasogastric tube hasbeen removed, and alimentation is progressively resumed in linewith bowel function. The postoperative course is usually surpris-ingly uneventful. The hospital stay varies from 3 to 5 days.

Thoracoscopic Truncal Vagotomy

Although it is not a true laparoscopic procedure, thorascopictruncal vagotomy comprises bilateral truncal vagotomy on thelower part of the esophagus using the same method and the same

endoscopic instruments. As described by Wittmoser [10], it hasbeen performed traditionally in two steps separated by 3 weeksand was done in association with bilateral splanchnicectomy. Wehave described a simpler, one-step technique using a unilateralapproach, usually left thoracoscopy [1].

The patient is placed under general anesthesia with double-lumen endotracheal intubation, which permits exclusion of venti-lation of the lung on the side chosen. The patient is placed in alateral decubitus position as for a posterolateral thoracotomy. Thesurgeon is positioned facing the back of the patient with anassistant to his or her left.

To create the pneumothorax a short incision is made in the sixthintercostal space in the posterior axillary line, and a forceps isused to puncture the pleura and introduce air in the pleural cavity.The forceps is replaced by a 8- or 10-mm trocar for the scope, andthe full cavity is explored. If necessary the lung is deflated usingthe double-lumen tube. To avoid the theoretic possibility of airembolism, we prefer to inflate with CO2 using low-pressure in-flow, but it is not mandatory.

Pleural adhesions are eventually identified and freed, and thesites for the two other trocars are chosen on the middle axillaryline, as far as possible from each other to make the work easier(Fig. 10). A coagulating grasper is introduced through the lowertrocar, and the scissors and the hook are introduced alternativelythrough the upper trocar. It may be useful to place a fourth trocarfor a supplementary grasper or retractor.

The mediastinal pleura is opened longitudinally in front of theaorta for 3 to 4 cm. The left vagus is easily located as a single trunkor several smaller branches, which are coagulated and cut. Theesophagus is gradually freed on the entire circumference, and theright nerve is dissected, coagulated, and sectioned; any longitudi-nal nerve is also cut. The risk of hemorrhage at this level is lowbecause the area is almost avascular (Fig. 11). If the opposite

Fig. 5. Highly selective vagotomy. Isolation of the first pedicle on thelesser curve.

Fig. 7. Dor’s antireflux procedure.

Fig. 6. Highly selective vagotomy completed. (After Cadiere et al. [4],with permission of the author.)


pleura is entered, the high pressure in the right bronchial treecontrols it until the esophagus, back in its original mediastinalposition, obstructs the leak.

Once the vagotomy is completed, the intercostal spaces areinfiltrated with a local anesthetic, the lung is reexpanded, and thetrocars are withdrawn with intrabronchial high pressure. If thereis no identified bleeding or air leak, pleural drainage is unneces-sary. Otherwise, a small drain is left for a few days through theanterior trocar for air leak control.

Gastric Resection

Although there are few indications for gastric resection of uncom-plicated G-D peptic ulcers, various types of gastrectomy are pos-sible using laparoscopy. These techniques are described briefly.

I believe that the classic two-thirds gastrectomy as the onlytreatment of G-D ulcers should not be recommended, althoughwith antrectomy-vagotomy, which has a low rate of ulcer recur-rence, it is still the choice of some surgeons. Vagotomy-pyloro-plasty, despite its higher recurrence rate, is the procedure ofchoice for others.

The first step is to perform a bilateral truncal vagotomy. Theantrectomy begins with dissection of the greater curvature andpylorus, dividing the omental vessels, and similarly for the lessercurvature. At this point there are two possibilities [11]: (1) closethe proximal duodenum and the antrum with multiple shots of theendo-GIA stapler and perform a laterolateral gastrojejunal anas-tomosis on the anterior (or posterior) aspect of the gastric stump

with endo-GIA, closing the remaining defect with some stitches(Fig. 12); or (2) choose a mixed procedure: through a short rightsubcostal (or paraumbilical) miniincision, the antrum is exterior-ized and resected; the anastomosis is done by manual suturing.We have performed such a vagotomy-antrectomy with G-D anas-tomosis easily on two patients of normal weight; it should be moredifficult or impossible on obese patients.

Pyloroplasty. Pyloroplasty is feasible by laparoscopy, either aloneor in association with a vagotomy. To perform a Finney-typepyloroplasty, the pylorus is opened high anteriorly; and an endo-GIA stapler is introduced through a trocar placed high near thexiphoıd appendix. It is moved downward in the duodenum and theantrum, brought closer by a stitch. The endo-GIA stapler is thenfired, and the hole in the pylorus is closed by staples or by stitches.In the rare case where a pyloroplasty is necessary, we prefer to doit manually through a minilaparotomy once the vagotomy is doneby laparoscopy. Both Finney and Mickulicz pyloroplasties arefeasible.

Excision of the Ulcer. If the ulcer is gastric and persists despitedrug therapy or vagotomy, a biopsy is mandatory. If gastroscopyprovides a specimen that is not large enough, it may be necessaryto surgically excise the ulcer. It is not always possible by laparos-copy because of the difficulty of localization, inaccessible access,or extensive thickening of the wall. Sometimes excision is possible,as for a benign tumor, with scissors and repair by suture or a“linear resection” using an endo-GIA stapler. Only a few cases

Fig. 8. Anterior seromyotomy. Fig. 9. Anterior linear gastrectomy. (From Gomez-Ferrer [9], with permis-sion.)


have been reported and only by personal communication. Ohashidescribed a technique for intragastric surgery that may be avail-able for gastric ulcer excision [12].

Indications and Results

Because of the few indications for surgical treatment of uncom-plicated G-D ulcers, there are no large series with long-termresults for laparoscopic vagotomy; but there is no reason to be-lieve that such results would not be the same as in retrospectiveseries for the same procedures done with open surgery. However,it can be stated that the postoperative course of all videoscopicvagotomies is smooth, and the hospital stay is 3 to 5 days.

Up to 1992 we had performed thoracoscopic vagotomy in 21patients with only two complications: one case of phrenic paralysisand a case of 3 weeks of dysphagia. All the ulcers were healed at3 months, and there was one late recurrence in a case of alcohol-ism-induced pancreatitis [3].

Another 32 cases of laparoscopic truncal bilateral vagotomieswere reported with good results and no complications [13]. UsingTaylor’s procedure, 62 cases were reported (13) with no compli-cations, healing of the ulcers, and only two recurrences after 2years [14]. Another 32 cases of laparoscopic HSV were reportedwith no morbidity and only one early recurrence at 10 months [4].

With all types of vagotomy there is a 10% risk of gastric stasislinked to antropyloric malfunction. That stasis was erroneouslyattributed to a “pylorospasm.” In fact in these cases, with endos-copy the pylorus appears wide open. Physiologic studies [15] havedemonstrated that it was a kind of antropyloric “achalasia,” withon-site muscular contractions (without waves) leading to subnor-mal evacuation of liquids but stasis of solid meals. At the begin-ning we thought that it was necessary to perform balloon endo-

Fig. 10. Position of trocars during left thoracoscopy.

Fig. 11. Dissection of the right vagus during thoracoscopic vagotomy.

Fig. 12. Laparoscopic Billroth II antrectomy. (Endo GIA: endoscopicgastrointestinal anastomosis stapler. (After Goh [11], with permission ofthe author.)


scopic pyloric dilatation, but it seems that this dilatation is usefulonly in the presence of stenosis or real spasm. In other cases thestasis disappears in a few weeks when treated by dietetic meansand prokinetic drugs (erythromycin). Dietetic advice is useful forminimizing the “postvagotomy diarrhea” risk, but mostly preop-erative selection is necessary, avoiding vagotomy in patients withchronic severe diarrhea.

Resume

Bien que le traitement des ulceres gastroduodenaux ne soit quetres rarement chirurgical, on peut parfaitement concevoir, lorsquela chirurgie est indiquee, traiter la maladie par laparoscopie avecses avantages anticipes. La technique la plus utilisee est lavagotomie quelle que soit sa modalite. Un bon apprentissage enlaparoscopie ainsi qu’une bonne instrumentation sont obligatoirespour realiser cette intervention sans complications. Le type devagotomie peut etre tronculaire et bilateral, effectuee parlaparoscopie ou par thoracoscopie : c’est la methode la plus facileet la plus rapide, les sequelles sont moins graves et moinsfrequentes, comme cela a deja ete rapporte. On peut egalementpratiquer une vagotomie supra-selective ou mixte, comme dans latechnique de Taylor. De grandes series de ces techniques ont eterapportees dans la litterature avec de bons resultats. La resectiongastrique est rarement utilisee pour le traitement des ulceresgastro-duodenaux : neanmoins, elle est envisageable souslaparoscopie; ces interventions necessitent une grandeexperience. Les resultats a long terme des vagotomies parlaparoscopie sont actuellement publiees : ils sont similaires a ceuxattendus par chirurgie ouverte.

Resumen

Aunque el tratamiento de la ulcera peptica gastroduodenalraramente es quirurgico, cuando una intervencion sea necesaria,el abordaje laparoscopico, con todas sus bien conocidas ventajas,es posible y recomendable. La tecnica mas conocida es lavagotomıa en todas sus variantes tecnicas. Para evitar cualquiertipo de complicaciones se precisa un cirujano experto enlaparoscopia y un instrumental adecuado. La vagotomıa troncularbilateral puede realizarse por vıa laparoscopica o toracoscopica.Es una intervencion facil, rapida y sus complicaciones son menosfrecuentes e importantes que las que se observan tras cirugıa

convencional. Tambien puede realizarse una vagotomıa selectivao mixta, semejante al procedimiento de Taylor. Numerosostrabajos han demostrado buenos resultados. La reseccion gastricarara vez se utiliza como tratamiento de la ulcera peptica; sinembargo, si es necesaria tambien pude efectuarse por vıalaparoscopica, siempre y cuando el cirujano tenga una ampliaexperiencia. En la actualidad, existen resultados tardıos devagotomıas laparoscopicas que son totalmente superponibles a losobtenidos con cirugıa abierta.

References

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9. Gomez-Ferrer, F.: Gastrectomie lineaire anterieure et vagotomietronculaire posterieure par laparoscopie. J. Coeliochir. (France) 4:35,1992

10. Wittmoser, R.: Thoracoscopic sympathectomy and vagotomy. In: Op-erative Manual of Endoscopic Surgery, A. Cushieri, editor, Berlin,Springer-Verlag, 1992, pp. 110–133

11. Goh, P.: Laparoscopic Billroth II gastrectomy. Semin. Laparosc. Surg.1:171, 1994

12. Ohashi, S.: Laparoscopic intra-gastric surgery. Surg. Endosc. 9:169,1995

13. Avtan, L., Ozmen, V., Avci, C., Muslumanoglu, M., Buyucuncu, Y.:Video-endoscopic truncal vagotomies. Surg. Laparosc. Endosc. 7:439,1997

14. Mouiel, J., Katkhouda, N., Gugenheim, J.: Traitement electif del’ulcere duodenal par vagotomie tronculaire posterieure et sero-myo-tomie anterieure par laparoscopie. Chirurgie 121:335, 1996

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New Surgical Strategy for Gastroduodenal Ulcer: Laparoscopic Approach