The vagus nerves originate in the medulla oblongata, and most of its fibers are involved in forming the parasympathetic division of the autonomic nervous system. Multiple branches extend to both thoracic (esophagus, heart, lungs, bronchi) and abdominal (stomach, gallbladder, small intestine, colon, and other viscera) structures. After leaving the plexus surrounding the hilum of the lung, the vagal fibers reunite in two large lateral bundles on the left and right sides of the esophagus. A clockwise rotation of the nerves as they course inferiorly results in the left vagus nerve appearing anteriorly and the right appearing posteriorly as the trunks enter the abdominal cavity. Gastric branches run from both the anterior and posterior trunks as they course parallel and superior to the lesser curvature of the stomach, finally extending to the pylorus ( Fig. 10-1 ). Additional branches given off in the abdomen include hepatic branches from the anterior vagus and celiac branches from the posterior vagus.
There may be substantial variation in vagus nerve distribution around the esophagus as the trunks pass beyond the diaphragm into the abdomen ( Fig. 10-2 ). Although the great majority of cases (80%) involve a single large anterior and posterior trunk, other variations include multiple branches, fusing of branches, tangential branches, and plexiform branches. Awareness of these variations should result in a careful circumferential search of mobilized esophagus for any additional branches after presumed complete truncal vagotomy.
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