Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

The bougie is removed and the surgeon guides placement of a nasogastric (NG) tube into the lower pharynx to check for mucosal leaks. The surgical bed is filled with water to cover the suture/staple line while the anesthesiologist gently injects air through the NG tube. If no air bubbles are seen, mucosal integrity is intact. The staple line is left uncovered and a small Jackson-Pratt drain is placed in the surgical bed and exited through a separate stab incision in the neck laterally (Figure 15-8). A leak can be closed primarily with fine interrupted sutures and reinforced with muscle coverage.

Leak test

FIGURE 15–8

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3. CLOSING

Alternatively, if the muscular layers are intact they can be reapproximated. Retractors are removed and the platysma is closed with interrupted stitches using 4-0 absorbable suture. The drain is secured to the skin with a 4-0 silk stitch (Figures 15-9 and 15-10).

Diverticulum cut and stapled

Interrupted sutures

STEP 4: POSTOPERATIVE CARE

After recovery from anesthesia, the patient is returned to a floor bed, with no food allowed overnight. On the second postoperative day, a contrast esophageal swallow study is performed and a diet started if no leak is present.

The following day, the drain can be removed if no increase in output is observed after initiation of a diet. The patient can be discharged to home by the third or fourth postoperative day.

STEP 5: PEARLS AND PITFALLS

Recognize that Zenker’s diverticula are the sequelae of cricopharyngeal/esophageal dysmotility. Many patients will present with cricopharyngeal dysfunction (choking or aspiration or both) without a Zenker’s diverticulum. The goal of the operation is to address the dysmotility in a two-step process: myotomy followed by management of the diverticulum.

Recent retrospective reports with endoscopic stapler-assisted diverticulotomy and carbon dioxide laser endoscopic diverticulotomy present alternative therapies for Zenker’s diverticula. Advocates note shorter operative time, shorter hospital stay, and quicker return to diet. The techniques have not been shown to be superior to an open procedure, with a recurrence rate of approximately 10%. Carbon dioxide laser endoscopic diverticulotomy is also an alternative to open surgery, but likewise results in a higher failure rate.

SELECTED REFERENCES

1.Wirth D, Kern B, Guenin MO, et al: Outcome and quality of life after open surgery versus endoscopic stapler-assisted esophagodiverticulostomy for Zenker’s diverticulum. Dis Esophagus 2006;19:294-298.

2.Chang CY, Payyapilli RJ, Scher RL: Endoscopic staple diverticulostomy for Zenker’s diverticulum: Review of literature and experience in 159 consecutive cases. Laryngoscope 2003;113:957-965.

3.Chang CW, Burkey BB, Netterville JL, et al: Carbon dioxide laser endoscopic diverticulotomy versus open diverticulectomy for Zenker’s diverticulum. Laryngoscope 2004;114:519-527.

C H A P T E R 16

ESOPHAGECTOMY—TRANSHIATAL

David B. Loran and Joseph B. Zwischenberger

STEP 1: SURGICAL ANATOMY

A comprehensive understanding of the anatomy of the esophagus is critical before undertaking surgical procedures on the esophagus.

Figure 16-1 demonstrates key anatomic structures that must be considered before performing a transhiatal esophagectomy.

STEP 2: PREOPERATIVE CONSIDERATIONS

Indications for transthoracic esophagectomy include carcinoma, caustic injury with stricture or dysplastic mucosal changes, and other benign diseases. Most surgeons agree benign disease is best treated with transhiatal esophagectomy, which eliminates the risk of intrathoracic anastomotic leak and spares the patient the discomfort of thoracotomy without compromising outcomes. Carcinoma at any level of the esophagus can be safely resected by transhiatal approach. In performing a transhiatal esophagectomy, the surgeon removes accessible cervical, intrathoracic, and intra-abdominal lymph nodes for staging, but a complete en bloc resection of adjacent lymph node–bearing tissue is not accomplished.

Transhiatal esophagectomy results in a lower incidence of pulmonary complications compared with a transthoracic approach. Anastomotic leak rates range from 12% to 15% but have been shown to be approximately 3% with a stapled technique. When a leak does occur, the associated morbidity and mortality are less than that seen for leaks from an intrathoracic esophagogastrostomy.

Informed consent is obtained and the patient is made nothing-by-mouth status at least 8 hours before the procedure. A bowel preparation can be given to the patient the day before the procedure, in case the colon is needed as a reconstruction conduit. In the operating room, a radial artery catheter should be used for continuous blood pressure monitoring, because retrocardiac dissection can cause periods of hypotension. Central venous access is not routinely necessary; however, if needed, the right neck veins should be used to allow the surgeon complete access to the left side of the neck during operation. A standard endotracheal tube is used for intubation.

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STEP 3: OPERATIVE STEPS

1.INCISION

An upper midline supraumbilical incision from the xiphoid process to the umbilicus is used to begin the abdominal portion of the procedure. The exposure should be extended cephalad to excise the xiphoid process to gain maximum access to the esophageal hiatus. A selfretaining retractor can facilitate exposure of the upper abdomen (Figures 16-1 and 16-2).

Liver

Gallbladder

Stomach

Right gastroepiploic artery

Left gastroepiploic artery

FIGURE 16–2

2. DISSECTION

Upon entering the abdomen, the surgeon should perform careful inspection to search for metastatic disease and to ensure the stomach is free from scarring, shortening, or disease that will preclude its use as a suitable conduit for reconstruction.

The surgeon must be intimately familiar with the arterial anatomy of the upper abdomen and early in the course of the dissection must identify the left gastroepiploic artery and protect this artery throughout the operation (Figure 16-3).

Left gastric artery

Liver

Stomach

Gallbladder

Left gastroepiploic artery

Omentum

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To begin mobilization of the stomach, the left triangular ligament is taken down and the left liver lobe is retracted to the right. The greater omentum is separated from the greater curve of the stomach, beginning at an avascular plane approximately at the greater curve’s midpoint. Dissection is then carried superiorly to the esophageal hiatus, carefully ligating the left gastroepiploic artery and all short gastric vessels. Care must be taken to avoid pinching a portion of the stomach wall within ligature ties of the short gastric vessels, which can later lead to necrosis and perforation of the gastric wall. Once the surgeon has reached the esophageal hiatus, the peritoneum is incised and the distal esophagus encircled with a Penrose drain to aid in esophageal retraction and dissection. The lesser omentum is dissected from the lesser curve of the stomach, and the left gastric artery is ligated because its branches supply the lesser curve. All lymph nodes in the area should be included with the specimen. Identification and preservation of the right gastric artery along this dissection plane is attempted (Figure 16-4).

Next a pyloromyotomy is performed from 1 to 2 cm on the anterior gastric wall through the pylorus extending approximately 0.5 to 1.0 cm onto the duodenum. We prefer to use a fine-tipped hemostat and needle-tipped Bovie for careful dissection of the stomach and duodenum muscular wall away from the underlying mucosa. The surgeon must ensure the mucosa has not been violated. If the lumen of the bowel has been entered, the mucosal defect is closed primarily and Heineke-Mikulicz pyloroplasty is performed (Figure 16-5).

The hiatus is enlarged by small radial incisions of the crura to allow much of the esophageal dissection under direct vision through the hiatal keyhole. To complete the abdominal portion of the procedure, the Penrose drain is retracted downward, and the distal 10 to 15 cm of esophagus is mobilized through the hiatus by blunt and sharp dissection. At this point the surgeon must determine that the distal esophagus is free from adhesions or tumor or both to proceed with the operation.

To complete gastric mobilization, the remaining greater omentum is freed from the greater curve again, preserving the right gastroepiploic artery, and a Kocher maneuver is performed to ensure maximum gastric mobility.