Truncal vagotomy was performed by opening the esophagophrenic ligament and encircling the esophagus. Putting the esophagus on stretch as shown allows identification of the major vagal trunks which are isolated, elevated with a nerve hook and a segment removed between clips.
The left and right vagus in the neck divide and interconnect over the body of the esophagus to form the esophageal plexus. The plexus coalesces near the esophageal hiatus, usually forming two major trunks, with the anterior containing fibers mainly from the left and the posterior from the right (LARP: left-anterior, right-posterior).
For complete vagotomy all minor branches must also be divided. Variations of highly selective vagotomy (posterior truncal, anterior highly selective), preserving pyloric innervation and avoiding pyloroplasty, can be done in elective situations, usually laparoscopically.