Fig. 5.29   Highly selective vagotomy using harmonic scissors

Caution is necessary when using extensive electrocautery next to the lesser curvature, which could lead to injury to the organ and a seromuscular perforation. The author therefore recommends the use of clips rather than monopolar electrocautery on the lesser curvature itself. Alternatively, a highly selective vagotomy can be performed using harmonic scissors (Fig. 5.29). The great advantage is that there is no need to create windows. Harmonic scissors are welding tools that enable one to perform the operation safely in less than 2 h,minimizing lateral injury to the stomach or to the nerves of Latarjet.

Lesser Curvature Seromyotomy and Posterior Truncal Vagotomy

This is a technique that has been popularized in open surgery by T. V. Taylor and was performed by the author as the first published laparoscopic vagotomy technique. It combines a posterior truncal vagotomy, as described earlier, with an anterior lesser curvature seromyotomy. The anterior lesser curvature seromyotomy starts at the posterior aspect of the angle of His, proceeds parallel 10–15 mm from the lesser curvature, and ends approximately 6 cm from the pylorus at the first branch of the crow’s foot.

Both aspects of the stomach are grasped and the dissection is started by creating a small groove between the graspers, using an electrical hook. The combination of traction by the graspers and the electrocautery leads to exposure of the submucosal layer, which can be recognized by its blue color. It is not necessary to go beyond the submucosal layer.

Fig. 5.30  Posterior truncal vagotomy and anterior lesser curvature seromyotomy

If one crosses this layer, oozing will be encountered. The risk of opening the mucosa at this point is great. If one stays at the submucosal layer, the risk of opening the mucosa is absolutely minimal.

Starting at the angle of His, the seromyotomy goes down to include the last branch of the crow’s foot. It is recommended that two or three large vessels running on the anterior aspect of the stomach are divided before one starts the seromyotomy, as initially advocated by Taylor in open surgery (Fig. 5.30). This is done by using the harmonic shears.

When the seromyotomy is complete, a continuous suture is placed in an overlap fashion to bring the two edges of the stomach on each other. This will prevent nerve regeneration and blood oozing, and therefore postoperative adhesions (Fig. 5.31).