Hepatic vagal branch preservation vs. division during fundoplication: a narrative review

Background and Objective: The hepatic branch of the anterior vagus nerve plays an important role in regulating gallbladder motility and biliary function. During fundoplication for gastroesophageal reflux disease (GERD), surgeons may elect to divide this branch to improve crural dissection. However, such division has potential implications for postoperative biliary physiology and may increase the long-term risk of gallstone formation. This review examines clinical studies that compare outcomes between hepatic branch preservation (HBP) and hepatic branch division (HBD) during fundoplication. Methods: We reviewed studies that compared HBP vs. HBD during laparoscopic fundoplication. PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar databases were queried until 10th September 2025. Study design, population, interventions, follow-up, biliary/gastrointestinal physiologic outcomes [gallbladder ejection fraction (GEF), fasting volume, emptying time], laboratory markers, and symptoms were extracted. Key Content and Findings: Overall, three papers (one randomized trial and two observational studies) were included for a total of 83 patients; intentional HBD was reported in 51.8%. The age of the patient population ranged from 21 to 73 years, the majority were males (69%), and the preoperative body mass index ranged from 21.4 to 27.6 kg/m2. All patients underwent a laparoscopic Nissen fundoplication. Outcomes and methods for gallbladder physiology assessment varied across reports including fasting gallbladder volume (mL), GEF by scintigraphy or ultrasonography, gallbladder emptying time (GET), laboratory markers (amylase, liver enzymes), and patient-reported biliary symptoms. The included trial reported similar GEF and fasting volumes but prolonged GET for HBD vs. HBP (34 vs. 24 minutes). Observational reports found no consistent difference in symptoms, GEF or fasting volumes. None of the included study provided clinical endpoints for symptomatic cholelithiasis or cholecystectomy rates. Small sample size, limited follow-up durations, and heterogenous outcome measurement were limitations. Conclusions: The available evidence, which is limited and heterogeneous, does not clearly indicate short-term clinical consequences for HBD during fundoplication. Despite a tendency toward longer GET was reported, its clinical implication remains uncertain. At present, the evidence is inadequate to support either routine preservation or division of the hepatic vagal branch.