What technical procedures are available to prevent vagal inclusion in the valve?
B. Launois, E. Bardaxoglou, B. Meunier, S. Landen (Rennes)
The Nissen procedure is associated with potential long-term complications involving the development of gastric ulceration, the etiology of which remains controversial. One may speculate that, in the presence of pre-existent anomalies of gastric emptying, the added operative trauma to the vagus nerves could trigger the release of gastrin and subsequent ulcer formation. A number of authors consider vagus nerve injury to be a major contributing factor . Various technical artifices have been devised to avoid such trauma.
Isolation and exclusion of the vagus nerves
The vagus nerves are separated from the esophagus at the hiatus and reclined to the right, along with the hepatic plexus. Dissection is begun at the hiatus, down to and
not beyond the level of the esophago-gastric junction, where the vagus trunks become the anterior and posterior nerves of Latarjet.
The initial step consists in the ligation of the short gastric vessels at the upper aspect of the greater curvature. This will allow the mobilization of the stomach pouch to produce a tension free wrap. The abdominal segment of the esophagus is encircled with a tape, and the hernia sac is excised. The left vagus nerve is dissected from the esophagus, at the level of the hiatus, and great care is taken not to damage the hepatic branch which runs across the upper portion of the lesser omentum. The small direct nervous branches to the esophagus are severed from the hiatus down to the esophago-gastric junction, along with the terminal branches of the left gastric artery. More distally, the left branch of the vagus nerve runs parallel to the lesser curvature and becomes the anterior nerve of Latarjet. It is not unusual to find an early division of the anterior vagus nerve into two branches that run at the anterior aspect of the esophagus. The right vagus nerve is found posteriorly to the right of the esophagus. It is encircled with a vessel loop, and followed in the direction of the celiac ganglion. A large posterior branch arises from the main trunk, runs parallel and gives small branches to the esophagus, originating from the nerve at a right angle, and then descending towards EG junction. More distally, the posterior branch follows its course on the posterior part of the lesser curvature and constitutes the posterior gastric nerve of Latarjet.
At this level, the right and left vagus nerves along, with the hepatic branches are reclined a few centimeters to the right of the esophagus. The diaphragmatic crural slings are approximated posteriorly using 2-3 interrupted sutures. The posterior vagus trunk is carefully secured at the level of the hiatal orifice. The gastric pouch is then wrapped around the abdominal esophagus to constitute a valve that is 2-3 cm wide, and that should not lie below the esophago-gastric junction. The right and left margins of the wrap should be approximated with sutures anchored to the anterior aspect of the esophagus.
Isolation of the anterior vagus trunk
The anterior trunk is not dissected away from the esophagus and is included in the wrap.
Supraselective vagotomy 
When associated to Nissen fundoplication, this procedure obviously implicates denervation of the upper part of the fundus, but the vagus nerves are carefully preserved, as is antro-pyloric function.
The etiology of gastric ulceration after Nissen fundoplication remains controversial. If vagus nerve injury is suspected to play a role, then avoiding entrapment into the
gastric wrap appears logical. Several authors make reference to such measures, but fail to be explicit on the technical details of the procedures. Herrington  was the first to propose measures aimed at avoiding vagus nerve damage. Indeed, it is conceivable that the anterior branch may be injured if included in the bites taken on the anterior esophageal wall while anchoring the wrap. Likewise, the posterior branch may be damaged while approximating the crural sling fibers. Supraselective vagotomy may be considered, in some views, as the best technical artifice to prevent damage to the nerves, but the technique described by Herrington appears to induce a greater traumatism than when the nerves are included in the wrap. However, as of yet there are no randomized studies that prove this.