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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
18722 Intrathoracic Esophago-Gastrostomy …
Fig. 22.7 Anvil and stapler are connected (a, b) and anastomosis is done (c)
Fig. 22.8 The donuts are
checked up
188 C. Rosman and B. Klarenbeek
Fig. 22.9 Lateral gastric loop is stapled. Close (a) and schematic view (b)
Fig. 22.10 The staple line is reinforced. Close (a) and schematic view (b)
Fig. 22.11 The anastomosis
is covered by omentum wrap
fixed to the pleura
18922 Intrathoracic Esophago-Gastrostomy …
Fig. 22.12 Jackson Pratt
drain is left along the
anastomosis
Reference
1. Oesophago-Gastric Anastomosis Study Group on behalf of the West
Midlands Research Collaborative. International variation in surgical practices in units performing oesophagectomy for oesophageal
cancer: a unit survey from the oesophago-gastric anastomosis audit
(OGAA). World J Surg. 2019;43(11):2874–84.
Intrathoracic EsophagoGastrostomy After MIE Ivor Lewis
Resection: End-To-Side HandSewn Anastomosis
Guy-Bernard Cadiere and Benjamin Cadiere
23
23.1 Description of the Surgical Technique
(see Video 23.1)
The key steps of the hand-sewn intrathoracic anastomosis
are:
1. Position of patient and placement of trocars
The patient is positioned in prone position for right
thoracoscopy. Three trocars are placed in line from the
inner edge of the scapula, at intercostal spaces 5th, 7th,
and 9th. Insufflation of 7–8 mm Hg is used (Fig. 23.1).
2. Posterior wall outer seromuscular layer
The esophagus is divided at the level of the azygos vein.
Gastric conduit is ascended into the thorax. Without tension is placed along the open end of the proximal esophagus (Fig. 23.2). The posterior seromuscular continuous
suture is done from medial to lateral without opening the
gastric conduit (Fig. 23.3).
3. Posterior inner mucosal layer
An opening is performed in the gastric conduit between
0, 5, and 1 cm from the first seromuscular suture. A second layer including the mucosa is performed with a continuous suture from medial to lateral (Fig. 23.4).
4. Anterior wall inner and outer layer
From medial to lateral the anterior opening is closed
with continuous invaginating stitches. First the inner
layer (Fig. 23.5) in a continuous fashion. This inner layer
is reinforced by a continuous sutured seromuscular outer
layer (Fig. 23.6).
5. Anastomosis is finished. Thoracic drain is placed
Reinforcement stitch is placed between the gastric con-
duit and the lateral aspect of the esophago-gastric anastomosis (Fig. 23.7).
6. Anastomosis is covered by omentum wrap (Fig. 23.8).
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_23) contains
supplementary material, which is available to authorized users.
G.-B. Cadiere (*)
Service de Chirurgie Digestive, UMC Saint-Pierre, Bruxelles,
Belgium
e-mail: Guy-Bernard_CADIERE@stpierre-bru.be
B. Cadiere
Department of Gastrointestinal Surgery, European School of
Laparoscopic Surgery, Saint-Pierre University Hospital, Université
Libre de Bruxelles, Brussels, Belgium
© 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_23
191
192 G.-B. Cadiere and B. Cadiere
Fig. 23.1 Patient in prone position; three trocars are placed between
the scapula and the spine
Fig. 23.2 A medial initial stitch
is placed to fix the esophagus to
the gastric tube. Close (a) and
schematic view (b)
Fig. 23.3 Continuous
posterior outer suture
seromuscular. Close (a, b)
and schematic view (c)
Fig. 23.4 Inner continuous
mucosal layer. Close (a) and
schematic view (b, c)
19323 Intrathoracic Esophago-Gastrostomy …
Fig. 23.5 The anterior inner
layer is sutured. Close (a) and
schematic view (b, c)
194 G.-B. Cadiere and B. Cadiere
Fig. 23.6 Suturing of the
outer layer is started on the
medial aspect, knotting at
the end of the suture with the
former inner suture’s end.
Close (a, b) and schematic
view (c)
Fig. 23.7 Reinforcement
stitch is placed between the
gastric conduit and the lateral
aspect of the esophagogastric anastomosis (a).
Anastomosis is finished and a
thoracic drain is placed (b)
Reference
1. Cadiere GB, Dapri G, Himpens J, et al. Ivor Lewis esophagectomy
with manual esogastric anastomosis by thoracoscopy in prone position and laparoscopy. Surg Endosc. 2010;24:1482–5.
Fig. 23.8 Omentum wrap to cover the anastomosis
Intrathoracic RobotAssisted Minimally Invasive
Esophagectomy (RAMIE) Ivor
Lewis End-To-Side Anastomosis
Ismael Diez del Val and Carlos Loureiro González
24
24.1 Description of the Surgical Technique (See Video 24.1)
The phases to perform a minimally invasive esophagectomy
(RAMIE-assisted) are:
1. Abdominal phase
The abdominal phase is carried out by conventional
laparoscopy. Once the lymphadenectomy has been completed and the gastric plasty tailored, the right pleura is
opened and the specimen is passed through it, followed
by the gastric tube itself, with a posterior closure of the
hiatal defect with a non-resorbable suture.
2. Thoracoscopic phase
After finishing the abdominal phase, the patient is
turned to the prone position, with two pillows (under
the sternum and the symphysis of the pubis) to allow the
abdominal respiratory movements during the period of
right lung collapse.
Intubation is usually selective, with a right lung collapse,
and an intrathoracic pressure of 4–8 mm Hg may be used to
make maneuvers easier.
Three 8-mm robotic trocars are placed as follows:
Immediately behind the tip of the scapula, for the introduction of a 30-degree scope.
2–3 intercostal spaces below (surgeon’s left hand) and 2
spaces above (right hand), and a bit backwards to create a
little triangulation.
A fourth 12-mm assistance trocar is placed anteriorly, in
the position where the pleural drain will be inserted at the
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_24) contains
supplementary material, which is available to authorized users.
I. Diez del Val (*) · C. Loureiro González
Department of Surgery, Hospital Universitario Basurto,
Bilbao, Spain
e-mail: ismael.diezdelval@osakidetza.net
end of the procedure (Fig. 24.1). This access must allow the
introduction of stapling, clipping, or sealing devices by the
table assistant.
The thoracic phase may be carried out by conventional
thoracoscopy or robot-assisted esophagectomy (RAMIE) [1].
It includes the en bloc esophageal dissection with its surrounding lymphatic tissue, which makes us to peel off the aorta,
pericardium, and the tracheo-bronchial membranous wall up to
the left pleura, with thoracic duct ligation. The lymphadenectomy goes up to the right (extended) with or without the left
(total) paratracheal space, particularly in case of squamous-cell
cancer and depending on the preoperative findings. It is compulsory to adequately visualize and preserve both laryngeal
recurrent nerves: the right one that recurs in a higher position
around the right subclavian artery, and the left one around the
aortic arch, running parallel to the left tracheal edge.
The key steps for a robot-assisted minimally invasive
intrathoracic esophago-gastric anastomosis are (see
Video 24.1): [2]
1. Once the resection has been completed, the esophagus is
sectioned above the azygos vein (Fig. 24.2), the surgical
specimen left aside and the gastric tube placed with the
staple line toward the camera.
The surgeon can choose between:
A conventional esophago-gastric anastomosis, end-to-
side or end-to-end by thoracoscopy, or
2. To do the anastomosis by robot-assisted minimally inva-
sive esophagectomy (RAMIE). The Da Vinci surgical
system is docked, placing a grasper in the left hand and a
needle holder in the right (Fig. 24.3).
3. In case of stapled esophageal end, a barbed V-lock
or 3/0 running suture will fix both, the proximal esopha-
gus and the gastric tube (Fig. 24.4).
4. After opening both structures, by excision of the esopha-
geal stapled line and the gastric tube, a posterior and an
anterior running suture is performed to create the anasto-
mosis (Figs. 24.5 and 24.6).
®
2/0
© 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_24
195
196 I. Diez del Val and C. Loureiro González
5. If the esophageal stump was already opened (the
mucosal layer is left one centimeter longer than the mus-
cular one), two running barbed sutures are performed
directly, and tied over a single clip to make it visible in
plain radiographs.
6. The lateral part of the gastric conduit is resected by a
stapler (Fig. 24.7). The nasogastric tube is placed distal
to the anastomosis in an intrathoracic position. The final
aspect of the anastomosis is given in Fig. 24.8.
7. The anastomosis is wrapped using the omental flap [3, 4]
in order to reduce the risk of postoperative anastomotic
leaks.
8. The specimen and the redundant gastric tube are
Fig. 24.1 Placement of trocars for RAMIE intrathoracic anastomosis
removed through a mini-thoracotomy.
9. Thoracic cavity is drained.
Fig. 24.2 Three arms are used, holding the camera, a grasper, and a
needle holder. The vision cart is placed to the left of the patient-side
cart (this one coming from the left thorax)
Fig. 24.3 Section of the
proximal esophagus with
linear stapler. Close (a) and
schematic view (b)
Fig. 24.4 The stump of the esophagus and the gastric conduit are approximated with running sutures, first posterior and then anterior in two
layers. Close (a) and schematic view (b)
19724 Intrathoracic Robot-Assisted Minimally …
Fig. 24.5 If the esophageal stump is opened (the mucosal layer is left one centimeter longer than the muscular one) (a, b, c). Two running
barbed sutures are performed directly, and tied over a single clip to make it visible in plain radiographs (d, e)