The approach for a selective gastric vagotomy is a right paramedian incision extended to the xiphisternum. The lesser omentum is incised so that an instrument can be passed behind the left gastric artery and vein. The vagal branch also lies at this site: all three are ligated and divided.
The peritoneum is now divided up to the base of the oesophagus, and very carefully, vessels and nerves along this route are ligated down to the level of the outer gastric muscle. The oesophagus is now displaced to the left and further dissection of vessels and nerves is carried out on its right side and posteriorly. Care is taken to avoid dividing the main posterior trunk of the vagus which passes to the coeliac plexus.
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