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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
102 R. M. Reddy
Fig. 13.6 Kocher maneuver. Schematic (a) and close view (b, c)
Fig. 13.7 Assessing pylorus
reach to hiatus
(Fig. 13.6). The duodenum is mobilized until the pylorus
is free enough to be brought to the hiatus, which indicates
enough length for the gastric conduit to reach the neck.
The next step is to assess pylorus reach to hiatus
(Fig. 13.7).
13.2.4 Steps Through Hand Port
Supraumbilical—7 cm (Fig. 13.8)
A 7 cm vertical incision is made extending the camera port
site 2 cm inferior and 5 cm superior. A gel port retractor is
inserted. The remaining greater omentum is freed from the
gastroepiploic artery to the level of the pylorus.
To perform the pyloromyotomy (Fig. 13.9), two
figure-of-eight 3-0 silk sutures are placed at the superior
and inferior borders of the anterior pylorus. These sutures
are used to ligate the veins of Mayo as well as place the
pylorus on tension and elevate it from the wound. A 2-cmlong pyloromyotomy is performed using the cut current of
a needle-tipped electrocautery. The pyloromyotomy should
start on the stomach 1.5 cm from the pylorus and extend
0.5–1 cm onto the duodenum. A fine-tipped mosquito
clamp is used to gently dissect and elevate muscle fibers of
the pylorus away from the underlying gastroduodenal submucosa. If the mucosa is entered, the injury can be repaired
or converted to a pyloroplasty. The pylorus is marked for
future radiographic localization with silver clips placed on
the silk stay sutures.
Fig. 13.8 Hand port position
All posterior adhesions from the stomach to the pancreas
are freed which allows for maximum mobilization of the
conduit (Fig. 13.10). If the Kocher is incomplete, it can be
further extended through this incision also.
10313 Robot-Assisted Minimally Invasive Transhiatal Esophagectomy
We then perform an open 14-Fr rubber jejunostomy
feeding tube placement 20–25 cm beyond the ligament of
Treitz and secured in place using a Witzel maneuver. The
red rubber is modified with 6–8 more holes created along
the distal half of the tube. The tube is temporarily clamped
using large clips and placed in the abdomen. The gel port
cap is placed over the wound protector and attention taken
to the neck.
13.2.5 Mobilization of the Cervical Esophagus
and Resection
A 5–7 cm oblique left cervical incision is made parallel to
the anterior border of the sternocleidomastoid muscle. The
omohyoid muscle is identified and divided. The sternocleidomastoid and carotid sheath are retracted laterally, while an
index finger is used to retract the trachea and thyroid medially. Care is taken to avoid direct pressure on the recurrent
laryngeal nerve in the tracheoesophageal groove. The inferior thyroid artery and middle thyroid vein may be divided
for better exposure. The prevertebral fascia is identified,
and blunt finger dissection is used to define the esophagus.
Upward traction on a 1-inch Penrose drain placed around
the cervical esophagus facilitates blunt mobilization of the
upper thoracic esophagus from the superior mediastinum.
If the mediastinal dissection was performed to 2 cm
above the level of the carina, the esophagus is usually completely freed. If there is still some mediastinal mobilization,
Fig. 13.9 Open
pyloromiotomy
104 R. M. Reddy
Fig. 13.10 Posterior gastric
mobilization (stomach is
pulled through the hand port)
the hand-assist port allows for a hand to placed upward
from the esophageal hiatus using finger dissection with the
left hand while simultaneously working downward through
the cervical incision using a curved sponge stick with the
right hand.
Dissection is first carried out along the posterior aspect
of the esophagus staying as close to the spine as possible to
avoid compressing the heart.
Once the posterior dissection is completed, a 28-Fr
Argyle Saratoga sump catheter is inserted through the cervical incision to evacuate blood from the mediastinum.
Dissection of the esophagus then proceeds along the lateral
attachments.
Lastly, the anterior attachments are taken down by dissecting posteriorly toward the esophagus and away from
the posterior pericardium and membranous trachea. After
mobilization, the upper esophagus is delivered into the cervical wound. The nasogastric tube is pulled back into the
oropharynx, and the esophagus is divided with a gastrointestinal anastomosis (GIA) surgical stapler. An Allis clamp
is placed on the staple line of the cervical esophagus to
prevent it from retracting into the wound. The stomach and
thoracic esophagus are then delivered out of the abdominal
incision.
fundus with variable conduit width (Fig. 13.11). Distal margins should be at least 4–5 cm from the tumor.
The surgical specimen is then removed from the field,
and the gastric staple line is oversewn with a running 4-0
Prolene Lembert stitch.
13.2.6 Gastric Conduit Creation and Passage Through the Posterior Mediastinum to the Neck
The esophagus and proximal stomach are then separated
from the remaining stomach with serial applications of a
GIA stapler. The transection line should begin along the
lesser curvature of the stomach approximately 4–5 cm distal to the esophagogastric junction and proceed toward the
Fig. 13.11 Gastric conduit creation
Fig. 13.12 Assessing length
of gastric conduit
Fig. 13.13 Gastric pull up
to the neck through posterior
mediastinum
10513 Robot-Assisted Minimally Invasive Transhiatal Esophagectomy
We will perform a conduit perfusion scan using nearinfrared spectroscopy and indocyanine green dye administration to confirm adequate blood flow.
Once length of gastric conduit (outside) has been
assessed (Fig. 13.12), the gastric conduit is then gently
manipulated through the esophageal hiatus and advanced
manually upward through the posterior mediastinum. The
fundus is grasped with a Babcock clamp that is placed
through the cervical wound and gently manipulates the conduit upward (Fig. 13.13). A small mosquito clamp is placed
on a ligated short gastric artery near the tip of the gastric
conduit to prevent it from retracting back into the mediastinum. The cervical wound is then covered with a moist
thoracic pack, while the abdominal portion of the case is
completed.
13.2.7 Narrowing the Hiatus
The three non-midline robotic ports are replaced and the
abdomen reinsufflated with the gel port maintaining pressure. The robot is re-docked now with the camera in the
first left-sided port (first right hand). A needle driver is
placed in the second right-hand port and a ProGrasp back in
the left-hand port.
The esophageal hiatus is narrowed to two fingerbreadths
using interrupted 1-0 silk sutures (Fig. 13.14). The closure
should include the parietal peritoneum as suture through the
crural muscle alone may tear. A hand can be placed through
the gel port to assess for the level of narrowing while
maintaining insufflation. When adequately narrowed, the
liver paddle retractor is removed and the 12 mm port site
106 R. M. Reddy
Fig. 13.14 Hiatal narrowing. Schematic (a) and close view (b, c)
closed intra-abdominally using a Carter-Thompson tool to
place 2 2-0 vicryl ties across the port site. The robot is then
dedocked, and the gel port and wound protector removed.
The jejunostomy tube is brought out through the first righthand port site and tacked to the adjacent peritoneum with
interrupted 3-0 silk sutures. The tube is also secured at the
level of the skin with 2-0 prolene suture. The 7 cm midline
incision is then closed in standard fashion. The port site
skin incisions are closed with 4-0 moncryl.
13.2.8 Cervical Esophagogastric Anastomosis According to Orringer
The cervical esophagogastric anastomosis is performed following closure of the abdomen. The tip of the gastric conduit is pulled out of the neck, and a 3-0 silk seromuscular
traction suture is placed along the anterior wall as distal as
possible. The site of the anastomosis is then determined,
and a 1.5 cm vertical gastrostomy is made in the anterior
wall of the stomach. When determining where to place the
esophagogastric anastomosis, it is important to leave some
redundant esophageal length to avoid traction on the anastomosis as the gastric conduit will partially retract into the
mediastinum. The stapled end of the cervical esophagus is
amputated and submitted as the proximal esophageal margin. Two 4-0 Vicryl stay sutures are placed to facilitate
alignment of the posterior wall of the esophagus and the
anterior wall of the stomach. The first stitch is placed at
the proximal end of the gastrostomy and through the posterior corner of the cut esophagus. The second stitch is a
retraction stitch placed through the anterior corner of the
cut esophagus. A side-to-side anastomosis between the cervical esophagus and gastric fundus is performed using the
Endo GIA 30-purple tri-staple load (Fig. 13.15). The trac-
tion sutures are gently retracted downward as the stapler is
Fig. 13.15 Cervical esophagogastric anastomosis. End to side Orringer anastomosis (a). Set up for hand-sewn portion of the anastomosis (b).
Anastomosis complete (c)
10713 Robot-Assisted Minimally Invasive Transhiatal Esophagectomy
advanced ensuring that the posterior wall of the esophagus
and anterior wall of the stomach are well-aligned. Once the
stapler is closed, two 4-0 Vicryl seromuscular sutures are
placed between the esophagus and stomach on both sides
of the stapler. The stapler is then fired creating a 3 cm sideto-side anastomosis. A nasogastric tube is carefully guided
across the anastomosis and secured at 40–45 cm from the
nares to ensure the tip is located in the intrathoracic conduit but not beyond the pylorus. The anterior opening of
the anastomosis is then closed in 1 or 2 layers. The inner
mucosal layer is closed with running 4-0 PDS, while the
outer later if performed is done with interrupted 4-0 PDS
sutures. A small metallic hemoclip is placed on either side
of the anastomosis for future radiographic localization. The
cervical wound is then irrigated, and a 1/4-inch Penrose
drain is positioned next to the anastomosis. The deep muscle is loosely approximated with two interrupted 3-0 vicryl sutures, the platysma with four interrupted 3-0 vicryl
sutures, and the skin edges are closed with running 4-0
nylon. Dry sterile dressings are applied to all incisions. A
postoperative chest radiograph is obtained in the operating
room while the patient is intubated to determine the need
for a chest tube in the event that a pleural injury was unrecognized and a pneumothorax or hemothorax is present.
References
1. Ilson DH, van Hillegersberg R. Management of patients
with adenocarcinoma or squamous cancer of the esophagus.
Gastroenterology. 2018;154:437–51.
2. Washington K, Watkins JR, Jay J, Jeyarajah DR. Oncologic resection in laparoscopic versus robotic transhiatal esophagectomy.
JSLS. 2019;23(2).
3. Kukar M, Ben-David K, Peng JS, et al. Minimally invasive Ivor Lewis esophagectomy with linear stapled anastomosis associated with low leak and stricture rates. J Gastrointest
Surg. 2019;16.
4. Zheng B, Zhang S, Zeng T, et al. Minimally invasive esophagectomy with three fields (2.5-field and cervical-field) lymph node
dissection with esophageal suspension method. J Thorac Dis.
2019;11:3183–5.
5. van Hillegersberg R, Boone J, Draaisma WA, et al. First experience
with robot-assisted thoracoscopic esophagolymphadenectomy for
esophageal cancer. Surg Endosc. 2006;20:1435–9.
6. Dunn DH, Johnson EM, Morphew JA, et al. Robot-assisted transhiatal esophagectomy: a 3-year single-center experience. Dis
Esophagus. 2013;26:159–66.
Minimally Invasive Esophagectomy: Ivor Lewis
Misha Luyer and Grard Nieuwenhuijzen
14
14.1 Introduction
Once the decision has taken to resect an esophageal cancer,
there are two main surgical minimally invasive esophagectomy (MIE) approaches: the transthoracic (the two-staged
Ivor Lewis esophagectomy or three-staged McKeown
esophagectomy) and the transhiatal esophagectomy (THE).
The decision for the surgical approach is based on the
surgeon´s discretion, since there is no evidence about the
best surgical approach in terms of morbidity and oncological outcomes yet.
Indications for two-staged Ivor Lewis esophagectomy
are considered the GE junction tumors type I and II, and the
rest of esophageal cancers up to the carina in which a free
resection margin of at least 5 cm has to be obtained. Tumors
treated by neoadjuvant therapy, chemotherapy, or chemoradiation can also be approached by this approach.
Minimally invasive Ivor Lewis esophagectomy is the
perfect approach for all these tumors, but still are controversial issues such as the extension of the lymphadenectomy
and the perfect intrathoracic anastomosis. There are different types of anastomosis: the linear side-to-side, the circular
stapler end-to-side anastomosis (by means of conventional
stapler or the Orvil technique), the manual end-to-side anastomosis, and the robot-assisted anastomosis. Currently,
there is no evidence which is the best anastomosis.
The technique of the linear side-to-side anastomosis is
adapted from the technique for the Roux-Y gastric bypass
for the treatment of morbidly obese patients and has been
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_14) contains
supplementary material, which is available to authorized users.
M. Luyer (*) · G. Nieuwenhuijzen
Gastro-Intestinal and Oncological Surgery, Catharina Hospital,
Eindhoven, The Netherlands
e-mail: misha.luyer@catharinaziekenhuis.nl
implemented since 2012. Over the years, the technique has
changed on several parts and is now standardized since
2016. More importantly, the surgical technique is only part
of a perioperative care pathway that is performed at the
Catharina Hospital by a dedicated team of scrub nurses,
anesthesiologists, intensivists, nurse specialists on the ward,
dieticians, physiotherapists, and surgeons who are involved
in the treatment. The surgery is performed fully via a minimal invasive technique and consists of a laparoscopic and a
thoracoscopic phase.
14.2 Description of the Surgical Technique (see Video 14.1)
Three important phases can be considered for the MI Ivor
Lewis esophagectomy:
1. Laparoscopy,
2. Thoracoscopy in prone, and
3. Intrathoracic linear side-to-side anastomosis.
14.2.1 Laparoscopic Phase
1. The laparoscopic phase of the procedure is performed
with the patient under general anesthesia, in French
reverse Trendelenburg position, with the surgeon
between the legs, the assistant surgeon on the right
side, and the scrub nurse on the left side of the patient.
Five abdominal ports are used (2 of 5 mm and 3 of
12 mm) (Fig. 14.1).
2. The greater curvature is mobilized using a sealing
device, by dividing the short gastric vessels until the
left crus of the diaphragm with preservation of the right
gastroepiploic arcade and an omental flap. Working
to the right side, the greater curvature is mobilized
© 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_14
109
110 M. Luyer and G. Nieuwenhuijzen
4. Below the level of the crowfoot, the right gastric
artery is divided and the lesser omental sac opened
(Fig. 14.4).
5. A formal D2 lymph node dissection is performed rou-
tinely from the liver hilum over the celiac axis until the
splenic hilum. The left gastric artery is divided after the
placement of Hem-o-lok clips (Fig. 14.5a–f).
6. The gastric conduit is measured at 4.5 cm using a felt
pen, and the gastric tube is created using Endo-GIA™
Tri-Staple™ XL 45 mm purple staplers. Starting from
the gastric angle, 4,5 cm wide, transection of the gastric tube is performed at the level of the watershed of
the gastroepiploic arteries. Staple line crossings are
oversewn (Fig. 14.6a–g).
Fig. 14.1 Operating room setup and placement of trocars
7. Using Near-Infrared Spectroscopy (NIRS), there is a
clear demarcation of the well-perfused part of the gastric conduit, and at that point the gastric conduit is tran-
completely and the right gastroepiploic pedicle is dissected and preserved. Moreover, an omental flap is created (Fig. 14.2a–c).
3. Transverse colon is mobilized, and a limited Kocher’s
maneuver is performed to ensure that the pylorus
reaches the hiatus (Fig. 14.3a–c).
sected (Fig. 14.7).
8. The distal esophagus is dissected through the hiatus, and by opening both pleural cavities and dividing
both inferior pulmonary ligaments, an en-bloc lower
para-esophageal lymph node dissection is performed
until the level of the pulmonary vein. A thorax drain is
left in the left thoracic cavity. Hiatus is completely dissected (Fig. 14.8a–c).
Fig. 14.2 Mobilization of greater curvature, preservation of gastroepiploic arcade, and creation of omental flap (a–c)
Fig. 14.3 Transverse colon is freed and a limited Kocher´s maneuver is performed. Close (a,b) and schematic view (c)
Fig. 14.4 The lesser omental sac is divided below the level of the
crowfoot the right gastric artery
9. A cruroplasty is performed (Fig. 14.9a, b).
10. The gastric conduit is then fixed to the resection
specimen which is placed in the left pleural cavity
(Fig. 14.10a–d).
11. Jejunostomy is constructed (Fig. 14.11a–c).
11114 Minimally Invasive Esophagectomy: Ivor Lewis
14.2.2 Thoracoscopic Phase in Prone Position (Single-Lumen Tube)
1. Place the patient in prone position, single-lumen tube.
Four thoracoscopic ports are used in the right thorax.
An insufflational pleural pressure of 8 mm H2O is
maintained (Fig. 14.12).
2. The pulmonary ligament is further divided, and the
mediastinal pleura overlying the esophagus is divided
to the level of the azygos vein (Fig. 14.13).
3. The azygos vein is transected using an Endo-GIA™
Tri-Staple™ 30 mm vascular stapler (Fig. 14.14a, b).
4. The right vagus nerve is divided just distal from its
most distal pulmonary branch (at the inferior edge of
the right bronchus).
5. The esophagus is freed from the membranous part
of the trachea, and the left main bronchus is exposed
(Fig. 14.15).
6. The dissection is also continued more cranially to
ensure liberal space for the future gastric conduit and
the side-to-side anastomosis. The distal esophagus and
the para oesophageal lymph nodes are then mobilized
circumferentially (Fig. 14.16a).
Fig. 14.5 D2 lymphadenectomy of the liver hilum, celiac trunk, and splenic artery. Schematic (a–c) and close views (d–f)
112 M. Luyer and G. Nieuwenhuijzen
Fig. 14.6 Measurement of the gastric tube, creation of gastric tube, transection of the gastric tube, and oversew the crossing staple lines.
Schematic (a,b) and close views (c–g)
Fig. 14.7 NIRS showing a well-vascularized gastric tube
7. The thoracic duct is clipped distally and proximally
and included in the resected specimen (Fig. 14.16b).
8. The infracarinal lymph nodes are removed as last
part of the mediastinal para-esophageal lymph node
dissection. In case of a squamous cell carcinoma or
pathological nodes on preoperative staging, a lymph
node dissection is performed at the level of the aortopulmonary window and right or left paratracheal
carefully preserving the vagus and recurrent nerves
(Fig. 14.17a–c).
9. The esophagus is dissected free above the carina in
order to create enough space for a side-to-side anastomosis. The proximal esophagus is transected using
Endo-GIA™ Tri-Staple™ 60 mm purple (Fig. 14.18a,
b).
Fig. 14.8 Transhiatal dissection of the distal esophagus and para-esophageal lymphadenectomy. Close (a,b) and schematic view (c)