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

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Now that the proximal and distal esophagus is mobilized, the transhiatal dissection is begun to fully mobilize the remaining esophagus is continued. Continuous traction is placed on each of the Penrose drains encircling the ends of the esophagus while the surgeon bluntly develops the prevertebral plane with his or her right hand through the hiatus and left hand through the cervical incision (Figure 16-10).

Stomach

Heart

Esophagus

Tumor at distal end of esophagus

Descending aorta

FIGURE 16–10

A Penrose drain is looped around the esophagus and retracted superiorly while blunt dissection of the esophagus is continued to the level of the carina. Dissection can be performed under direct vision through the enlarged hiatus, by blunt finger dissection, or using a thoracoscope (Figure 16-11).

Esophagus

Heart

SVC

Thoracic duct

Cisterna chyli

Azygos vein

FIGURE 16–11

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A sponge on a stick can help facilitate this dissection from the cervical incision. Once the entire posterior esophagus is mobilized, the anterior section is mobilized in similar fashion. During the anterior dissection, the surgeon must be careful not to injure the membranous portion of the trachea. The lateral esophageal attachments can be freed under direct vision from the hiatus with superior retraction of the chest wall. Lymph nodes in the subcarinal area should be dissected free and removed with the specimen. If the lateral attachments cannot be viewed, an alternative method is to insert the surgeon’s right hand through the hiatus and pin the esophagus against the spine between the index and middle fingers. The lateral tissue is then stripped from the esophagus by blunt dissection (Figures 16-12 to 16-14).

Esophagus

Diaphragm with radial incisions for enlargement

FIGURE 16–12

Heart

Esophagus

Diaphragm

FIGURE 16–13

Diaphragm

Esophagus

FIGURE 16–14

The stomach is then manipulated through the enlarged hiatus to the cervical incision. A Babcock clamp can be inserted from the cervical incision into the posterior mediastinum to help grasp and deliver the fundus of the stomach into the neck (Figure 16-17).

FIGURE 16–17

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Alternatively, a Penrose drain can be sutured to the apex of the stomach and delivered into the cervical incision to help provide traction. Both techniques use more pushing from the diaphragm side rather than pulling from the neck side. The surgeon must be careful to avoid twisting the stomach, which will compromise gastric blood flow and can lead to conduit necrosis with anastomotic breakdown (Figures 16-18 to 16-20).

The abdominal portion of the procedure is completed before the cervical anastomosis is performed. This allows time to assess the viability of the gastric conduit. In the abdomen, the hiatus is closed by approximating the crura with 2-0 Vicryl figure-of-eight stitches to easily allow 2 fingerbreadths between the stomach and hiatus. The stomach is also tacked to the diaphragm with interrupted 3-0 silk stitches to prevent subsequent gastric herniation into the chest. At this point a jejunostomy feeding tube can be placed according to surgeon preference.

Heart

Stomach

FIGURE 16–18