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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
156 M. A. Acosta and S. Navarro Soto
Fig. 18.7 The anterior
opening is closed by means
of a 60 mm linear stapler.
Close (a) and schematic
views (b). Final vision (c)
Fig. 18.8 Gastric conduit is oversewn with continuous reabsorbable
3.0 suture. The gastric conduit is exteriorized through the cervical
wound
Fig. 18.9 The two ends
of the anastomosis are put
together. Gastric conduit
posterior and proximal
esophagus anteriorly. Close
(a) and schematic views (b)
Fig. 18.10 A horizontal
opening is made 4 cm from
the tip of the gastric conduit.
Close (a) and schematic
views (b)
15718 Cervical Esophagogastric Anastomosis
Fig. 18.11 Posterior line is sutured by continuous suture
Fig. 18.12 Check up the
patency of both the openings
(a, b)
158 M. A. Acosta and S. Navarro Soto
Fig. 18.13 A nasogastric
tube is passed through the
esophagogastric anastomosis,
distally, into the gastric
conduit.
Fig. 18.14 Anterior suture is made by continuous reabsorbable 3.0
suture
References
1. Vilela Castro PM, Gonçalves Ribeiro FP, et al. Hand-sewn versus stapler esophago-gastric anastomosis after esophageal resection: systematic review and meta-analysis. Arq Bras Cir Dig.
2014;27:216–21.
2. Valverde A, Hay JM, Fingerhut A, et al. Manual versus mechanical
esophagogastric anastomosis after resection for carcinoma: a controlled trial. French Associations for Surgical Research Surgery.
1996;120:476–83.
Fig. 18.15 Check up the patency of the anastomosis
3. Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical
esophagogastric anastomosis leak with a side-to-side stapled anastomosis. J Thor Cardiov Surg. 2000;119:277–88.
4. Ishibashi Y, Fukunaga T, Mikami S, et al. Tripled-stapled quadrilateral anastomosis: a new technique for creation of an esophagogastric anastomosis. Esophagus. 2018;15:88–94.
Intrathoracic EsophagoGastrostomy After MIE Ivor Lewis
Esophageal Resection: End-ToSide Anastomosis by Means
of Circular Stapler. The Flap
and Wrap Technique
Suzanne S. Gisbertz and Mark I. van Berge Henegouwen
19
19.1 Introduction
The anastomosis will be performed after complete mediastinal lymphadenectomy and mobilization of the esophagus.
The abdominal lymphadenectomy and gastric tube creation have been performed earlier, by laparoscopy during the
abdominal phase.
19.2 Description of the Surgical Procedure (see Video 19.1)
Key steps to perform an end-to-side intrathoracic circular
anastomosis are as follows.
19.3 Thoracoscopic Phase in Prone Position
1. The gastric tube is pulled up in the thorax without
touching the tube itself. First, the cardia is pulled up
and the gastric tube will partially follow. Next, the
tube is pulled up even more by grasping the omentum
(without grasping the gastroepiploic vessels). The tube
is pulled up so far that the beginning of the first staple line (at the angulus of the stomach) is intrathoracic,
always taking care not to rotate the gastric tube (omentum at the aortic side, Fig. 19.1).
2. The esophagus is transected using diathermia. For the
muscle layer, the blend mode is used, for the mucosa
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_19) contains
supplementary material, which is available to authorized users.
the coagulation mode is used at first, to coagulate this
highly vascularized tissue, followed by the blend mode
to finish the complete transection. The nasogastric tube
is pulled back into the esophagus (5 cm), (Fig. 19.2).
3. A mini thoracotomy (after blocking the right lung) is
performed at the most caudal trocar opening (approximately 9th intercostal space) and a wound protector is
placed.
4. The specimen is exteriorized and the cardia and gastric tube are separated with a 60 mm linear stapler.
The staple line is oversewn with interrupted sutures
(Fig. 19.3).
5. The anvil of a 29 mm circular stapler is introduced into
the esophagus and secured with a purse string suture
(outside–inside–inside–outside, etc., the so-called
‘baseball stitch’, Fig. 19.4).
6. The length of the gastric tube is measured using the
interrupted sutures (make it as straight and tight as possible, without tension).
7. The mesentery of the gastric tube is skeletonized until
the level of the future anastomosis.
8. The stapler is introduced into the gastric tube (still outside the patient, through the mini thoracotomy), and the
tip of the stapler is lead out at the skeletonized mesenteric side of the gastric tube (Fig. 19.5).
9. The two stapler parts are aligned and tightened very
slowly (1 min).
The stapler is fired and removed. Anastomosis is done
(Fig. 19.6). The doughnuts are checked for completeness and circularity.
10. The open end of the gastric tube is stapled with a linear
stapler 60 mm (Fig. 19.7).
11. The circular stapler line is oversewn at 2 levels. These
stitches are performed to release tension from the
anastomosis.
S. S. Gisbertz (*) · M. I. van Berge Henegouwen
Department of Surgery, Amsterdam University Medical Center,
Amsterdam, The Netherlands
e-mail: s.s.gisbertz@amsterdamumc.nl
© 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_19
159
160 S. S. Gisbertz and M. I. van Berge Henegouwen
Fig. 19.1 Gastric conduit is
pulled up into the thorax
Fig. 19.2 Esophagus is
transected by means of
diathermia. Close (a) and
schematic views (b)
12. The tip of the gastric tube is secured with one suture
underneath the pleural flap (this is the intact pleura
cranial from the level of the arch of the azygos vein).
Therefore, the gastric tube hangs partially from
the pleura, not only from the circular anastomosis
(Fig. 19.8).
13. The omental flap is wrapped around the gastric tube
and the anastomosis, making sure the trachea and bronchia are covered (Fig. 19.9).
14. The procedure is finished, a pleural drain is positioned,
the lung is inflated, and the wounds are closed.
Fig. 19.3 The specimen is exteriorized. Separated and oversewn
16119 Intrathoracic Esophago-Gastrostomy After MIE …
Fig. 19.4 The anvil of a 29 mm circular stapler is introduced into the esophagus and secured with a purse string suture, ‘baseball stitch’. Close
(a–c) and schematic views (d, e)
Fig. 19.5 The stapler is
introduced into the gastric
tube (a) and the tip of the
stapler is lead out at the
skeletonized mesenteric side
of the gastric tube (b)
Fig. 19.6 The two stapler
parts are aligned (a) and
the stapler is fired (b).
Anastomosis is done
162 S. S. Gisbertz and M. I. van Berge Henegouwen
Fig. 19.7 The open end of
the gastric tube is stapled.
Close (a) and schematic
views (b)
Fig. 19.8 The tip of the
gastric tube is secured with
one suture underneath the
pleural flap. Close (a) and
schematic views (b)
Fig. 19.9 Omentum wrap
Intrathoracic OesophagoGastrostomy After MIE Ivor
Lewis Resection: Side-To-Side
Oesophago-Gastrostomy
by Means of a Linear Stapler
Misha Luyer and Grard Nieuwenhuijzen
20
20.1 Description of the Operative Procedure (see Video 20.1)
The key steps to perform a side-to-side oesophago-gastrostomy by means of a linear stapler are:
1. The oesophagus is dissected free above the carina
in order to create enough space for a side-to-side
anastomosis.
2. The proximal oesophagus is transected using Endo-
GIA™ Tri-Staple™ 60 mm purple (Fig. 20.1a, b). A
linear side-to-side anastomosis is created between distal oesophagus and the gastric conduit.
3. The stapler line at the oesophagus is cut after placing
stay sutures. Mucosa and muscular at the oesophagus
are sutured (Fig. 20.2a–c).
4. A 34 Charriere tube is passed at the proximal oesopha-
gus (Fig. 20.3).
5. The specimen and the gastric conduit is advanced into
the thorax and both are disconnected by stapler. The
gastric conduit is placed near the proximal oesophagus
(Fig. 20.4a, b).
6. At 5 cm from the top of gastric conduit and close to the
vascular pedicle a small incision is made (Fig. 20.5).
7. The Endo-GIA 30 mm is inserted with its anvil in the
gastric tube (Fig. 20.6) and the stapler is advanced
guided by the 34 Charriere tube in the proximal
oesophagus and the tube retracted.
8. A side-to-side anastomosis is created (Fig. 20.7a, b).
9. The opening is now closed with a 3.0 V-Lock
two layers (Fig. 20.8a–d). No naso-gastric tube is left
through the anastomosis.
10. An omental wrap is placed around the anastomosis
(Fig. 20.9a, b).
11. And the crura is approximated (Fig. 20.10).
12. The specimen is placed in a bag and retrieved through a
small thoracotomy (Fig. 20.11a, b).
13. At the end, a conventional thoracic drain and a
Jackson-Pratt drain are placed along the anastomosis
(Fig. 20.12a, b).
®
in
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_20) 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
© 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_20
163
164 M. Luyer and G. Nieuwenhuijzen
Fig. 20.1 Transection of proximal oesophagus by means of linear stapler (a, b)
Fig. 20.2 Stay suture, the stapler line is cut and mucosa and muscular layers sutured (a, b, c)
Fig. 20.3 Charriere 34 Fr at
the proximal oesophagus
Fig. 20.4 Gastric tube and specimen in the thoracic cavity. Close (a) and schematic view (b)
Fig. 20.5 Top of the gastric
tube is opened
16520 Intrathoracic Oesophago-Gastrostomy …