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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
166 M. Luyer and G. Nieuwenhuijzen
Fig. 20.6 Endo-GIA 30 mm
inserted in the gastric tube
Fig. 20.7 Stapler is inserted in the proximal oesophagus and anastomosis is created (a, b)
16720 Intrathoracic Oesophago-Gastrostomy …
Fig. 20.8 Closure of the opening in two layers by means of a V-lock®. Close (a, b, c) and schematic view (d)
168 M. Luyer and G. Nieuwenhuijzen
Fig. 20.9 Omental wrap around the anastomosis. Close (a) and schematic view (b)
Fig. 20.10 Approximation
of the crura
Fig. 20.11 Retrieval specimen in a bag. Internal schematic (a) and external view (b)
16920 Intrathoracic Oesophago-Gastrostomy …
Fig. 20.12 Conventional drain in thoracic cavity and Jackson-Pratt along the anastomosis. Close (a) and schematic view (b)
Intrathoracic EsophagoGastrostomy After MIE Ivor
Lewis Resection: End-To-Side
Anastomosis by Means of a
Circular Stapler and Endoloop
Fernando Mingol Navarro
21
21.1 Description of the Operative Procedure (see Video 21.1)
The key steps to perform an end-to-side intrathoracic
esophago-gastrostomy anastomosis are:
1. Position of patient and placement of trocars
The patient is positioned in prone with a slight semi-
prone position. No selective intubation is used. Four
trocars are placed, three of 12 mm and one of 5 mm, as
one line at the inner edge of the scapula up to the 9th
intercostal space. Insufflation is used to collapse the
right lung between 7 and 8 mmHg (Fig. 21.1).
2. Transection of proximal esophagus
The esophagus is cut with scissors at the level of the
arch of the azygos vein (Fig. 21.2).
3. A purse string is made at the end of the proximal
esophagus
Before complete section a stitch is set at the anterior
wall of the esophagus for traction, being the beginning
of the purse string. The esophagus is completely cut as
the anterior purse string is set (Fig. 21.3).
4. The gastric conduit is advanced into the thorax and
the 28 mm anvil is placed into the esophagus
Gastric conduit is pulled up into the thorax and placed
without any torsion [1, 2]. The anvil of the 28 mm
®
device, introduced into the thorax, is placed in
EEA
the proximal esophagus and the purse string is knotted
(Fig. 21.4).
An Endoloop (R) is placed to reinforce the fixation of
the purse string around the inserted anvil (Fig. 21.5).
5. The EEA® device is introduced in the gastric conduit
A minithoracotomy is performed at the level of the
most distal placed trocar [1, 2] and the wound is protected by means of GEL POINT
Alexis® device with gel-cap. The gastric conduit is
exteriorized and is opened by the distal end. The EEA®
is inserted through the gel cap (of the device in order to
maintain the insufflation and collapse of the lung during the anastomosis) and introduced into the gastric
conduit (Fig. 21.6).
6. Circular anastomosis
The two ends of the 28 mm EEA® are joined conse-
quently, and the anastomosis is performed (Fig. 21.7).
7. The EEA is retrieved from the gastric conduit and the
two donuts inspected (Fig. 21.8).
8. The lateral loop of the gastric conduit is resected
Resection of the lateral end of the gastric conduit is
made by means of 60 mm endostapler (Fig. 21.9).
9. The end of this stapler section is reinforced with 2.0
interrupted stitches (Fig. 21.10).
10. Omentum wrap covered the anastomosis
The omentum is placed around the anastomosis and
gastric conduit as wrap. A clip is used to fix the omentum to the edge of the pleura (Fig. 21.11).
11. Drains are placed in the thoracic cavity (Fig. 21.12),
and trocars are retrieved with the control of possible
bleeding at the sites. Expansion of the lungs follows
under direct vision.
®
(Applied Medical)
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_21) contains
supplementary material, which is available to authorized users.
F. M. Navarro (*)
Department of Surgery, Esophageal Surgery Unit, Hospital
Universitario y Politécnico La Fé, Valencia, Spain
e-mail: mingolnavarro_6@hotmail.com
© 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_21
171
172 F. Mingol Navarro
Fig. 21.1 Position of the patient and placement of trocars
17321 Intrathoracic Esophago-Gastrostomy …
Fig. 21.2 Anterior wall of the esophagus is cut with scissors. Close (a, b) and schematic view (c)
174 F. Mingol Navarro
Fig. 21.3 Anterior aspect of the purse string. The purse string is completed. Close (a, b, c, d) and schematic view (e)
17521 Intrathoracic Esophago-Gastrostomy …
Fig. 21.4 Advancement of the gastric conduit into the thorax. The 28 mm anvil of the conventional circular stapler is introduced in the proxi-
mal esophagus. Close (a, b) and schematic view (c)
176 F. Mingol Navarro
Fig. 21.5 The purse string
is knotted and the Endoloop
is used to reinforce the purse
string around the anvil
®