A Look at Vagotomy
The simple cut that revolutionized ulcer treatment.
The vagus nerve, sometimes called the "wandering nerve," is a crucial communications cable in your body. Originating in the brainstem, it meanders through the neck and chest, finally reaching the abdomen, where it helps control everything from your heart rate and digestion to the very secretion of stomach acid9 . For much of the 20th century, deliberately cutting this nerve—a procedure known as a vagotomy—was the gold-standard surgical treatment for severe peptic ulcers5 . Though less common today due to modern medications, the story of vagotomy remains a fascinating chapter in medical history, and new, minimally invasive techniques are bringing this procedure back into the scientific spotlight3 6 .
This article explores the journey of vagotomy from a mainstream surgery to a specialized tool, detailing the different types of the procedure and the exciting new research that is reshaping its future.
In simple terms, a vagotomy is a surgical procedure that involves cutting or removing parts of the vagus nerve that innervate the stomach1 9 . Its primary purpose is to drastically reduce the production of gastric acid. For decades, it was a primary weapon against peptic ulcers—painful sores in the lining of the stomach or the first part of the small intestine (duodenum).
The rationale for the surgery is rooted in stomach physiology. Parietal cells in your stomach lining secrete acid, and they are stimulated by three primary mechanisms: the hormone gastrin, the chemical histamine, and the neurotransmitter acetylcholine, which is released in response to parasympathetic stimulation from the vagus nerve5 . By severing the vagus nerve, surgeons could eliminate the acetylcholine pathway, significantly dialing down acid secretion and allowing ulcers to heal1 5 .
Dietary management and antacids were the primary treatments for ulcers with limited effectiveness.
Vagotomy becomes the gold standard surgical treatment for severe peptic ulcers.
Discovery of Helicobacter pylori as a major cause of ulcers revolutionizes understanding.
Proton pump inhibitors (PPIs) and antibiotic therapies largely replace surgery for most ulcer cases.
New endoscopic techniques revive interest in vagotomy for refractory cases.
"The late 20th century saw a monumental shift with the introduction of acid-reducing medications like proton pump inhibitors (PPIs) and the discovery that the bacterium Helicobacter pylori is a major cause of ulcers1 5 . As a result, the need for vagotomy plummeted."
Today, vagotomy is largely reserved for complex cases where ulcers are refractory (do not respond to medication) or when complications like bleeding, perforation, or gastric outlet obstruction require surgical intervention2 5 .
Over the years, surgeons developed different types of vagotomy, each with a specific approach and set of trade-offs between effectiveness and side effects.
| Type of Vagotomy | What is Cut? | Key Advantage | Key Disadvantage & Required Additional Procedure |
|---|---|---|---|
| Truncal Vagotomy1 2 5 | The main trunks of the vagus nerve near the esophagus. | Highly effective at reducing acid; technically simpler. | Causes gastric stasis (solids don't empty well). Requires a drainage procedure like pyloroplasty. |
| Selective Vagotomy1 8 | Only the gastric branches going to the stomach, sparing branches to the liver and gallbladder. | Aims to reduce side effects like diarrhea and gallstones. | Still requires a drainage procedure and is technically more demanding than truncal vagotomy. |
| Highly Selective Vagotomy (HSV)1 8 | Only the nerve branches that stimulate the acid-producing part of the stomach (body and fundus). | Preserves antral and pyloric function; does not require a drainage procedure. | Highest ulcer recurrence rate (5-20%); technically very demanding5 7 8 . |
Cuts the main vagus nerve trunks. Most effective but requires drainage procedure.
Targets only gastric branches, sparing other organs. Still requires drainage.
Most precise, preserves stomach function. No drainage needed but higher recurrence.
While surgical vagotomy is now rare, researchers are exploring innovative ways to perform the procedure that are less invasive and potentially safer. A landmark 2025 feasibility study, published in VideoGIE, demonstrated a novel endoscopic approach for a truncal vagotomy in a porcine model3 6 .
The researchers aimed to replicate the effect of a surgical truncal vagotomy without any external incisions.
| Step | Procedure | Purpose |
|---|---|---|
| 1 | EUS Identification | To precisely locate the anterior and posterior vagus nerves. |
| 2 | Tattooing | To mark the nerves for targeted dissection. |
| 3 | Submucosal Tunneling | To create a safe, working tunnel to access the nerve area. |
| 4 | Fourth Space Dissection | To enter the correct anatomical plane where the nerves reside. |
| 5 | Nerve Transection | To achieve the goal of the procedure: cutting the vagus nerves. |
| 6 | Clip Closure | To securely close the internal incision and prevent leaks. |
The procedure was a technical success. The pig's vital signs remained stable throughout, and a post-procedure necropsy confirmed that both vagus nerves had been accurately tattooed and completely transected. Crucially, there was no evidence of leaks or injury to the surrounding mediastinal structures3 6 .
This experiment is scientifically important because it demonstrates the feasibility of a purely endoscopic approach to a major surgical procedure. It paves the way for "EUS-guided vagal modulation" as a potential future treatment for refractory hyperacidity syndromes. If successfully translated to humans, this technique could offer a treatment option with significantly reduced perioperative risk, cost, and recovery time compared to traditional surgery3 6 .
Whether in a historical surgical context or a modern experimental one, performing a vagotomy requires a specific set of tools and reagents.
| Tool/Reagent | Function & Explanation |
|---|---|
| Endoscopic Ultrasound (EUS) | Allows for real-time imaging and identification of the vagus nerves within the esophageal wall, crucial for targeting in new endoscopic techniques3 6 . |
| Fine-Needle Aspiration (FNA) Needle | Used to inject tattoo marker or other agents to pinpoint the vagus nerve's location for precise dissection3 6 . |
| Laparoscopic/Laparotomy Equipment | The standard set of surgical instruments, including a liver retractor and clip applier, used to access the abdominal cavity and perform the nerve resection5 . |
| Hemostatic Clips | Small metal or polymer clips used to occlude blood vessels and the cut ends of the nerve during surgery, or to close internal incisions in endoscopic procedures to prevent bleeding and leaks3 5 . |
| General Anesthesia | Essential for ensuring the patient or animal model is unconscious and pain-free during the invasive procedure2 . |
The story of vagotomy is one of medical evolution. It stands as a testament to surgical ingenuity in an era before the underlying causes of ulcers were fully understood. While its role in routine ulcer care has been rightfully supplanted by pharmaceuticals and antibiotic therapies, the principle of modulating gastric acid via the vagus nerve remains powerful.
Vagotomy represented a major advancement in surgical treatment for peptic ulcers during the mid-20th century, offering relief to countless patients who suffered from severe, medication-resistant ulcers.
New endoscopic techniques may revive vagotomy as a treatment option for select patients, particularly those with refractory conditions who aren't candidates for traditional surgery.
"The recent pioneering work in endoscopic vagotomy suggests that this is not a forgotten procedure, but a technique that may be on the cusp of a transformation. By moving from open surgery to minimally invasive, incisionless approaches, vagotomy could see a resurgence for a select group of patients for whom medications are not enough. The 'wandering nerve' continues to wander into new frontiers of medical science."