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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
Fig. 12.4 Opening of the
retroesophageal window
and place a sling around the
esophagus for traction. Close
(a) and schematic view (b)
Fig. 12.5 Maneuver
according to Pinotti. Close
(a) and schematic view (b)
9112 Laparoscopic Transhiatal Resection for Distal Esophageal …
Fig. 12.6 Anterior
mediastinal dissection along
the pericardial sac. Close (a)
and schematic view (b)
7. Lateral dissection is performed on both sides at the
level of the pleurae. The pleurae are always opened,
on both sides in most cases, with resection of some
part of it if necessary. The anesthesiologist is warned
of this situation because the mechanical ventilation
must be adapted. Mechanical ventilation is corrected
by means of increase of minute volume, use of positive end-expiratory pressure (PEEP), and decrease of
the insufflation pressure to about a 12 mmHg [6]. The
subcarinal esophagus is resected laparoscopically in
this way, together with paraesophageal tissue and periesophageal lymph nodes, to the level of the carina
(Figs. 12.10a, b and 12.11a, b).
8. By retracting the stomach and dividing the adhesions present in the lesser sac, an extensive lymphadenectomy of the celiac trunk and their branches is
92 M. A. Cuesta and D. L. van der Peet
performed, to be followed by division of the left gastric
artery and vein by means of a sealing device or clips.
From there, the dissection is completed up to the hiatus
(Fig. 12.12a–c).
9. The sealing device is used to mobilize the greater curvature of the stomach by dividing the gastro-colic ligament, with preservation of the gastroepiploic vessels.
Afterward, the short gastric vessels are approached and
divided up to the left crus of the hiatus (Fig. 12.13a–c).
(These two steps, 7 and 8, can be performed in different orders, first lymphadenectomy followed by gastric dissection or first gastric dissection followed by
lymphadenectomy)
10. A second surgeon perform the dissection of the cervical esophagus through a left-side cervical incision
(Fig. 12.14a, b).
11. At the same time, another surgeon performs and intro-
Fig. 12.7 Anterior dissection. View of the pulmonary vein
Fig. 12.8 Post mediastinal
dissection along the aorta.
Close (a–c) and schematic
view (d)
duce the left hand through a small assistance periumbilical incision (7 cm) with protection. Through the
Fig. 12.9 Anterior dissection up to carina
Fig. 12.10 Lateral right
mediastinal dissection. Close
(a) and schematic view (b)
9312 Laparoscopic Transhiatal Resection for Distal Esophageal …
lateral left trocar, a venous stripper is introduced into
the gastric lumen by a small incision in the lesser gastric curvature and then pushed up to the cervical dissected esophagus (Fig. 12.14a). If the stripper cannot
be pushed because of the obstruction caused by the
tumor, the feeding or the nasogastric tube can be withdrawn via the small opening in the stomach and then
exteriorized. The stripper then can be attached to the
tube and pushed up to the cervical esophagus. The
cervical esophagus is divided, after which the most
distal part is closed around the head of the stripper.
A nasogastric tube is attached to it. This can be used
afterward to lead the gastric conduit upside to the cervical incision.
12. In this way, with the hand of the surgeon in the abdomen, the controlled stripping can be safely performed.
In most patients, branches of the vagal nerves must be
Fig. 12.11 Lateral left
mediastinal dissection. Close
(a) and schematic view (b)
94 M. A. Cuesta and D. L. van der Peet
Fig. 12.12 Lymphadenectomy of the celiac trunk (a). Division of the left gastric artery (b). Final aspect after lymphadenectomy (c)
Fig. 12.13 Dissection of the great curvature (a). Up to the left cruz (b). Schematic view (c)
Fig. 12.14 Placement of
the stripper through proximal
stomach (a). Cervical
incision and division of the
esophagus (b)
divided at this stage to retrieve the specimen through a
fully protected periumbilical incision (Fig. 12.15a-e).
13. Once the specimen is retrieved outside the abdomen, the
mobilization of the stomach is completed, and the gastric
tube is created, 3–4 cm width, by using stapling device.
The gastric tube then is oversewn and attached to the
nasogastric tube and replaced in the abdomen (Figs. 12.16a,
b and 12.17a, b). Next, the pneumoperitoneum is reestablished, and the gastric tube is placed under vision into the
cervical esophagus by traction of the nasogastric tube
(Fig. 12.18a–c). A hand-sewn cervical anastomosis is created by using a one-layer suture technique.
9512 Laparoscopic Transhiatal Resection for Distal Esophageal …
Fig. 12.15 Stripping and exteriorization of the specimen through the Alexis device (a, b). Close (c) and schematic view (d) of the exterioriza-
tion of the stomach. Preparation of the stomach for creation of the gastric conduit (e)
Fig. 12.16 Construction of
the gastric conduit. Close (a)
and schematic view (b)
96 M. A. Cuesta and D. L. van der Peet
Fig. 12.17 Length of
the conduit. Close (a) and
schematic view (b)
Fig. 12.18 Close (a) and schematic view (b) of the pass the conduit to the neck, followed by cervical anastomosis (c)
14. Through the transumbilical incision, a jejunostomy
tube was placed for feeding and the two thoracic cavities were drained by two thoracic drains placed through
the trocar openings. In none of the patients in this
series was a Kocher maneuvre, a pyloromyotomy, or a
pyloroplasty performed.
Postoperatively patients were extubated when hemodynamically and respiratory stable. Extubated patients were admitted to the ICU or the medium care ward and from there
sent to the regular ward.
Patients were fed through the jejunostomy feeding tube
from the first day after their operation, until the oral feeding
could be completely resumed.
Active mobilization and physiotherapy follow. On postoperative day 4, a swallow x-ray examination was performed to assess the anastomosis, the gastric conduit, and
the passage through the pylorus. When no leakage and a
good passage were seen, the nasogastric tube was removed
and oral feeding was started. Patients were discharged when
they were completely mobile and able to feed themselves
orally.
9712 Laparoscopic Transhiatal Resection for Distal Esophageal …
References
1. Orringer MB, Sloan H. Esophagectomy Without Thoracotomy. J
Thorac Cardiovasc Surg. 1978;76:643–54.
2. Omloo JMT, Lagarde SM, Hulscher JBF, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus. Ann Surg.
2007;246:992–1001.
3. Pinotti HW, Zilberstein B, Pollara W, Raia A. Esophagectomy without thoracotomy. Surg Gynecol Obstetr. 1981;152:345–7.
4. Scheepers JJ, Veenhof AA, van der Peet DL, et al. Laparoscopic
transhiatal resection for malignancies of the distal esophagus: outcome of the first 50 resected patients. Surgery. 2008;143:278–85.
5. Maas KW, Biere SS, Scheepers JJ, et al. Laparoscopic versus open
transhiatal esophagectomy for distal and junction cancer. Rev Esp
Enferm Dig. 2012;104:197–202.
6. Makay O, van den Broek WT, Yuan JZ, et al. Anaesthesiological
hazards during laparoscopic transhiatal esophageal resection: A
case control study of the laparoscopic assisted versus the conventional approach. Surg Endosc. 2004;18:1263–7.
Robot-Assisted Minimally Invasive Transhiatal Esophagectomy
Rishindra M. Reddy
13
13.1 Introduction
Esophageal cancer is a leading cause of cancer-related
death in around the world. Surgery, along with chemotherapy and radiation when indicated, offers the best chance
for long-term survival; with multiple surgical approaches
being used [1]. Historically, the two main approaches
to esophageal resection have been transthoracic (Ivor
Lewis esophagectomy) with a mediastinal anastomosis
and transhiatal with a cervical esophogastrostomy. Other
approaches include the three-hole (McKeown) esophagectomy and now different minimally invasive approaches,
which are all modifications of the transhiatal [2], transthoracic [3], or three-hole operations [4]. Concerns raised
about the transhiatal approach include lower lymph node
counts and technical challenges with the “blind” posterior mediastinal dissection. We will focus on the operative
technique of the robot-assisted minimally invasive transhiatal esophagectomy (RAMI-THE) [5, 6], utilizing the Xi
DaVinci platform (Intuitive Surgical, Sunnyvale CA).
13.2 Description of the Surgical Technique
The key steps to perform a robotic-assisted transhiatal
esophagectomy (see Video 13.1) are as follows.
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_13) contains
supplementary material, which is available to authorized users.
R. M. Reddy (*)
Department of Surgery, Section of Thoracic Surgery,
University of Michigan, Ann Arbor, MI, USA
e-mail: reddyrm@med.umich.edu
13.2.1 Position of the Robot Xi DaVinci Platform
(Intuitive Surgical, Sunnyvale CA)
Following induction of general anesthesia and intubation
with a single-lumen endotracheal tube, a flexible esophagogastroscopy is performed to note the location and extent
of the esophageal lesion. Extension of the tumor through
the gastroesophageal junction and onto the stomach may
preclude the use of a minimally invasive approach if the
gastric conduit is not feasible and a colon interposition is
required for reconstruction. After removal of the esophagogastroscope, a nasogastric tube is placed to decompress the
stomach.
13.2.2 Patient and Trocar Position
The patient is positioned supine with a folded blanket
placed beneath the shoulders to facilitate neck extension.
The head is turned to the right, and the arms are padded and
tucked at the sides. The neck, chest, and abdomen should
be prepped into the operative field. Port sites are marked
beginning with an 8 mm vertical camera port 11 cm below
the xiphoid. A single “left” arm 8 mm port is marked 6 cm
to the left, and two “right” arm 8 mm ports are marked 6 cm
and 12 cm to the right of the camera port (Fig. 13.1).
A veress needle insertion is made through the inner
right arm port site which is in the left upper quadrant and
the abdomen inflated to 15 mm Hg. Once the initial port is
placed, the remaining three ports are placed under direct
vision. A liver paddle retractor is placed through a 12 mm
disposable port placed in the right lateral abdominal wall,
lateral and inferior to the “left” arm port (Fig. 13.1). A
ProGrasp retractor is placed in the left-handed port, a vessel
sealer in the 1st right-handed port, and a tip-up retractor in
the 2nd right-handed port. The tip-up is used to retract tissue, allowing for the ProGrasp and vessel sealer to serve as
primary dissection tools.
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_13
99
100 R. M. Reddy
Fig. 13.1 Trocar position
13.2.3 Mobilization of the Stomach and Esophagus
The upper abdomen and liver are examined for metastatic
disease, and the stomach is examined for evidence of tumor
involvement and suitability for conduit creation.
The course of the right gastroepiploic artery is identified
and preserved as the greater omentum is separated from the
stomach beginning at the midpoint of the greater curvature
and extending to the hiatus using the vessel sealer, including division of short gastric vessels (Fig. 13.2).
The left crus is then mobilized and the distal 3–4 cm of
the esophagus from 11 to 5 o’clock (looking at the hiatus)
(Fig. 13.3).
We then use energy to dissect through the gastrohepatic
ligament, which is examined for an aberrant left hepatic
artery. If an aberrant hepatic artery is identified, it is preserved and the left gastric artery divided distal to the origin
Fig. 13.2 Division of the short gastric vessels. Schematic (a) and close view (b, c)
Fig. 13.3 Dissection of the crura. Schematic (a) and close view (b, c)
Fig. 13.4 Mediastinal
dissection (a, b)
10113 Robot-Assisted Minimally Invasive Transhiatal Esophagectomy
of the aberrant artery. If there is no aberrant artery, the left
gastric artery is divided near its origin from the celiac trunk.
With either approach, the artery is skeletonized to resect the
associated celiac axis and gastrohepatic lymph nodes.
The right crus is mobilized, connecting the 11 o’clock
position counterclockwise to the 5 positions. Dissection is
carried out circumferentially now as high on the esophagus
as possible with identification and resection either individually or en bloc of any mediastinal lymph nodes (Fig. 13.4).
Along the anterior surface, dissection is carried out until
the subcarinal space is identified where subcarinal lymph
nodes can be resected (Fig. 13.5). The posterior plane is
dissected with aortic perforators resected with energy as
needed. During the lateral dissections, the pleurae will be
seen and can be kept intact, but if entered, an urgent bedside
chest tube and/or reduction of the level of insufflation may
be needed. If the pleura is entered, visualization and direct
mobilization of the more proximal esophagus becomes
more challenging, once maximum proximal dissection is
achieved.
With the Xi, a Kocher maneuver can be performed
using the tip-up to roll the duodenum to the patient’s left
Fig. 13.5 Subcarinal exposure. Close (a, b) and schematic view (c)