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392 Part III Esophagus
By this point, a separate midline abdominal incision will
have been performed, and blunt dissection is begun on the
esophagus from the abdomen. A two-team approach should
be considered with one team at the neck, while the other prepares the gastric conduit. e gastric conduit is elevated to
the neck with traction and the gastroesophageal junction is
divided. e pharyngogastrostomy anastomosis is performed
using a single-layer, interrupted hand-sewn anastomosis with
a nonabsorbable suture. e cervical tracheostomy is performed above the sternal notch. If too much trachea has been
resected to allow for this, manubrial resection will permit
placement of the end tracheostomy lower in the midline.
STRATEGY FOR LESIONS BELOW
THE THORACIC INLET
Lesions below the thoracic inlet can be divided according
to their location in the upper esophagus (below the thoracic inlet but above the carina), midesophagus (between
the carina and inferior pulmonary vein), or lower esophagus
(below the inferior pulmonary vein). While we favor the triincisional approach for all malignant lesions (for reasons to
be discussed later), lesions in the upper thoracic esophagus
generally must be approached with this technique to ensure
adequate proximal margins. If the lesion is in the midthoracic esophagus, either the tri-incisional approach or the Ivor
Lewis approach may be adequate. Lower esophageal tumors
can be resected with either of these two approaches, or additionally with a transhiatal approach or left thoracotomy and
distal esophagectomy. With any resection, accommodation
must be made for additional resection with reconstruction if
frozen margins are involved with tumor.
Transhiatal Versus
Transthoracic Techniques
Numerous retrospective analyses have been performed
comparing the transhiatal to the transthoracic (mainly
Ivor Lewis) approach. ese are summarized in two
meta-analyses. Rindani and associates reviewed 44 trials
involving either Ivor Lewis or transhiatal esophagectomy
that were published in the English language between 1986
and 1996.
plications, or pneumonia was no dierent between the two
groups. Dierences were seen in the anastomotic leak rate
(16% transhiatal vs 10% Ivor Lewis), stricture rate (28%
transhiatal vs 16% Ivor Lewis), and incidence of recurrent
nerve injury (11% transhiatal vs 5% Ivor Lewis). Mortality
was higher after the Ivor Lewis approach (9.5%) than the
transhiatal approach (6.3%). Long-term survival was about
25% with either technique. Hulscher and colleagues also
performed a meta-analysis of 50 studies published between
1990 and 1999 involving transthoracic and transhiatal
resection.
22
Overall, the incidence of bleeding, cardiac com-
23
Cardiac complications (20 vs 7%), anastomotic
leakage (24 vs 7%), and vocal cord paralysis (10 vs 4%)
were higher in the transhiatal group as opposed to the
transthoracic group. Pulmonary complications (19 vs 13%),
in-hospital mortality (9 vs 6%), and operative time (5 vs 4.2
hours) were higher in the transthoracic group. Overall longterm survival was similar between the two groups (23% for
transthoracic and 21.7% for transhiatal resections). ese
reviews are retrospective and nonrandomized, and caution should therefore be used in applying these ndings to
individual institutions and patients.
ree prospective, randomized trials have been performed
comparing transhiatal to transthoracic resection. e rst was
24
published in 1993 by Goldmine and associates.
Sixty-seven
patients younger than 70 years with squamous cell cancer
were randomized to Ivor Lewis resection or transhiatal resection. Operative time was longer (6 vs 4 hours) in the Ivor
Lewis group. ere was no dierence in the incidence of
pneumonia (20%), anastomotic leak, recurrent nerve injury,
bleeding, perioperative mortality, or length of hospital stay.
For those patients with nodal disease, however, none of the
transhiatal patients was alive at 18 months, while 30% of the
transthoracic patients were alive at 18 months.
Chu and coworkers randomized 39 patients with lower-
third esophageal cancers to either Ivor Lewis or transhiatal
25
resection.
Limitations of the study were small sample size,
short follow-up (mean 15 months), and patient exclusions.
Patients undergoing neoadjuvant therapy or those with
forced expiratory volume in 1 second (FEV
) less than 70%
1
of expected were excluded. ere were no perioperative
deaths in either group. Intraoperative hypotension occurred
in 60% of transhiatal patients but only in 5% of transthoracic
patients. ere was no dierence in blood loss, pneumonia,
or recurrent nerve injury. e mean proximal margin was
3cm longer in the transhiatal group. No signicant dierence was seen in tumor recurrence or survival during the brief
follow-up period.
A study comparing transhiatal resection to transthoracic,
tri-incisional en bloc resection for distal adenocarcinoma of
the esophagus or cardia was performed in the Netherlands.
One hundred and six patients were randomized to transhiatal resection and 114 patients to transthoracic resection. In-hospital mortality was 2–4% in each group. Chyle
leak was higher in the transthoracic resection group (10 vs
2%). Respiratory complications including atelectasis and
pneumonia were higher in the transthoracic group (57 vs
27%). Although statistical signicance was not reached,
39% of the transthoracic group was alive at 5years, while
26
only 29% of the transhiatal group survived 5years.
Metaanalyses show that the incidence of bleeding, ischemic
cardiac events, and length of stay are not necessarily dierent between the transthoracic and transhiatal approaches.
Placement of the anastomosis in the cervical position
appears to increase the risk of recurrent laryngeal nerve
injury, anastomotic leak, and stricture. e mortality rate
from an anastomotic leak, however, is less than that of a
leak in the chest. e transthoracic approach increases
operative time and in-hospital mortality.
Chapter 18 Surgical Procedures to Resect and Replace the Esophagus 393
An update of this study following with a full 5-year follow-up
continued to show no statistically signicant overall survival in
27
either approach.
However, in a subgroup of patients who had
one to eight positive lymph nodes in the resection specimen,
the transthoracic approach (TTE) demonstrated improved
overall survival compared with the transhiatal approach (THE)
(39% TTE vs 19% THE, p = .05). Disease-free survival was
similarly improved with the transthoracic approach (64% TTE
vs 23% THE, p = .02).
e randomized trials show no statistically signicant
dierence in survival, but they are small, and trends toward
improved survival are observed in patients undergoing transthoracic dissection. No dierence in mortality, blood loss, or
A
incidence of pneumonia was detected. It should also be noted
that unlike the meta-analyses, the randomized trials showed
no dierence in recurrent nerve injury or anastomotic leak.
is is a testament to the importance of experience and
volume in preventing these complications. Wong noted intraoperative hypotension in 60% of transhiatal dissections, but
28
in only 5% of transthoracic dissections.
is nding conrms every surgeon’s experience with transhiatal resection.
While some may argue that transhiatal dissection may be less
taxing on an elderly or debilitated patient (either because of
shorter operative time or avoidance of a thoracotomy), the
operation may be more taxing to a patient with severe cardiac valvular or atherosclerotic disease who cannot tolerate
uctuations in blood pressure. In these patients, transthoracic
esophagectomy is safer.
SURGICAL APPROACHES TO LESIONS
BELOW THE THORACIC INLET
Tri-incisional Esophagectomy
(McKeown Technique)
e tri-incisional technique of esophageal resection combines
the most attractive aspects of the Ivor Lewis and transhiatal
approaches. It allows for dissection of the intrathoracic esophagus
under direct vision with complete nodal resection and brings the
anastomosis to the neck, allowing for maximal proximal margins and minimizing the risk of an intrathoracic leak.
Under general anesthesia, bronchoscopy is performed
to rule out tracheal or bronchial (most commonly left main
bronchial) involvement with tumor. Esophagogastroduodenoscopy is performed to localize the tumor and rule out
disease of the stomach or duodenum. e patient is then reintubated with a double-lumen endotracheal tube and placed
in the left lateral decubitus position. A right posterolateral
thoracotomy incision is made large enough, approximately 10
cm in length, to introduce the surgeon’s hand (Fig. 18-3). e
serratus muscle is spared. Division of the intercostal muscles
anteriorly and posteriorly often permits adequate rib spreading without the need to remove a small portion, or shingle,
a rib. e chest is entered through the fth or sixth interspace depending on the location of the tumor. e inferior
B
FIGURE 18-3 A. e right chest has been entered through
the fth interspace. A piece of the posterior sixth rib has been
“shingled” to aid in exposure. e lung is retracted anteromedially,
and the mediastinal pleura has been incised posteriorly to expose
the esophageal tumor. Inset: e patient is placed in the left lateral
decubitus position. e dotted line marks the skin incision for
a right posterolateral thoracotomy. B. e latissimus muscle is
divided as caudally as possible, and the serratus muscle is spared
and reected medially.
pulmonary ligament is divided using electrocautery, and the
lung is retracted anteriorly.
Dissection of the esophagus begins at a point away from
tumor and any associated scarring, and the esophagus is
encircled with a Penrose drain. Traction on the Penrose drain
allows for cautery dissection encompassing all adjacent nodes.
Arterial branches directly o the aorta are clipped or ligated.
e settings on the electrocautery should be low when cauterizing near the trachea. e azygos vein is typically divided,
although this is not always necessary (Fig. 18-4). At this level,
the vagus nerves are identied. Dissection cranial to this level
involves the vagus nerves; the vagus nerves are peeled o and
away from the esophagus to avoid injury to the recurrent
vagus branches.
394 Part III Esophagus
FIGURE 18-5 With countertraction applied to the Penrose drain
encircling the esophagus above the tumor, blunt nger dissection is used
to develop the tracheoesophageal plane to and above the thoracic inlet.
FIGURE 18-4 e esophagus has been isolated circumferentially at
a point superior to the tumor and encircled with a Penrose drain. An
endostapling device is used to divide the azygos vein near its caval
connection.
Dissection between the trachea and esophagus must be
done with care and with low cautery dissection to avoid
injury to the membranous trachea. Much of the dissection
high in the chest can be done bluntly (Fig. 18-5). e cranial
aspect of the dissection is complete when one’s ngers reach
easily above the rst rib. e Penrose drain is knotted and
passed into the lower neck with the knot against the vertebral body for later retrieval during the neck phase of the
dissection (Fig. 18-6).
Another Penrose drain is used to gain traction on the
lower esophagus and dissection continues caudally. All tissue
between the pericardium, aorta, and azygos vein is dissected
and incorporated into the specimen. No eort is made to
resect the thoracic duct, although it is sometimes injured. For
tumors near the gastroesophageal junction, a rim of diaphragm
is incorporated into the specimen. e knotted Penrose drain
is placed in the abdomen for later retrieval (Fig. 18-7). At
this point, careful inspection is made for hemostasis and
injury to the thoracic duct. Often, injury to the thoracic duct
is evident when slightly cloudy or crystallized uid is seen
pooling in the region of the duct. If an injury to the duct is
seen, it should be closed with a pledgeted ne suture such as
5-0 Prolene. Mass ligature of the duct, as it enters the chest, is
then performed by encompassing all tissue between the spine,
aorta, and azygos vein at the level of the hiatus with a 0 silk
suture. A 28F straight chest tube is inserted via a separate stab
incision and directed to the apex of the chest. An additional
hole in the tube can be made to facilitate dependent uid
drainage. e ribs are reapproximated with 2-0 Vicryl sutures.
FIGURE 18-6 e knotted Penrose drain is pushed up through the
thoracic inlet and left to lie beneath the omohyoid muscle on the left
side of the neck.
Chapter 18 Surgical Procedures to Resect and Replace the Esophagus 395
e latissimus layer is closed using a running 0 Vicryl suture.
A subdermal layer is closed with 2-0 Vicryl and the skin is
closed in subcuticular fashion.
e patient is placed in the supine position and is reintubated with a single-lumen tube. A roll is placed under the back
to permit neck extension, and the head is turned to the right.
A midline laparotomy is performed from the umbilicus to the
xiphoid. Exploration of the abdomen should include a careful palpation of the liver and inspection of the serosal surfaces
for tumor implants. Palpation of the GE junction and proximal stomach should be performed to rule out gastric spread
of tumor. e left lobe of the liver is mobilized and retracted
to the right. e Penrose drain left from the chest dissection
is used for retraction of the GE junction (Fig. 18-8). e gastroepiploic artery is identied and palpated. e pulse should
be easily palpable provided the patient has a physiologic blood
pressure. Staying at least 2 cm away from the gastroepiploic
artery, the lesser sac is entered. Dissection continues cranially
on the stomach along the greater curvature. Dissection may be
performed by dividing tissue and ligating with 2-0 silk ties or
by using an ultrasonic scalpel. e stomach is retracted medi-
FIGURE 18-7 e lower Penrose drain is pushed down onto the
gastroesophageal junction below the diaphragm. e thoracic duct
is shown ligated, and a rim of the diaphragmatic hiatus encircles the
lower esophagus.
ally and the omentum laterally. e artery itself should not
be grasped or used for retraction. e gastroepiploic arcade
ends near the point where the short gastric arteries begin. A
pack placed behind the spleen often aids in exposure of the
short gastric vessels (Fig. 18-9). e short gastric vessels can be
ligated, double-clipped, or divided with an ultrasonic scalpel.
Large vessels should be tied. Care should be taken not to incorporate stomach wall in the ligature, as this may result in delayed
necrosis of stomach wall and a postoperative intrathoracicleak.
FIGURE 18-8 Exposure achieved by upper midline laparotomy. e large Balfour retractor is on the lateral abdominal walls, and the upper hand
retractor reects the liver to the right exposing the hiatus and lower Penrose drain around the GE junction.
396 Part III Esophagus
FIGURE 18-9 Gastric mobilization is begun at the superior greater
curvature near the hiatus. A rolled Mikulicz pad is placed behind the
spleen to aid in exposure. e short gastric vessels between the spleen
and the stomach are divided, and the transition zone between the left
and right gastroepiploic arteries is identied. Mobilization proceeds at
least 2 cm away from the right gastroepiploic arcade (dotted line).
Dissection on the greater curvature proceeds to the hiatus and
is complete when the Penrose drain is reached.
Proximal dissection on the greater curvature of the
stomach proceeds in likewise fashion. e gastroepiploic
artery migrates farther from the stomach as one dissects
toward the pylorus, and care must be taken not to injure
the vessel. e gastrohepatic ligament is divided with cautery up to the GE junction. e stomach is lifted anteriorly,
and thin adhesions between the stomach and pancreas are
divided with cautery. e left gastric vessels are approached
from behind the stomach (Fig. 18-10). e vessels are skeletonized, and lymph nodes are swept up onto the specimen. e vessels are clamped with a vascular endoscopic
30-mm stapler. e gastroepiploic pulse should be palpated
at this time to ensure that the celiac axis itself has not been
clamped, and the stapler is then red. e duodenum is
then mobilized using a Kocher maneuver, bringing it to the
midline (Fig. 18-11). A pyloromyotomy or pyloroplasty
may be performed with equivalent ecacy in aiding gastric
emptying. If a pyloroplasty is performed, it is best to close
it in a single layer with interrupted (3-0 silk) sutures. A leak
is exceedingly rare.
A neck incision is then made 6 cm in length along the
anterior border of the left sternocleidomastoid muscle starting at the sternal notch. Deep to the platysma, dissection
proceeds medial to the sternocleidomastoid muscle and
carotid sheath and lateral to the thyroid. e omohyoid
FIGURE 18-10 After the greater curvature is mobilized, the stomach
is reected superiorly and to the right, exposing the left gastric artery
and coronary vein. ese are ligated and divided with an endostapler,
near their origin, from the celiac axis.
can be divided with cautery (Fig. 18-12). Blunt dissection
is then used to approach the vertebral bodies (Fig. 18-13).
Lying along the vertebral body, the Penrose drain is grasped
and brought out into the neck wound with the encircled
esophagus. Proximally, the esophagus can be gently mobilized. e nasogastric tube is removed, and the esophagus
is divided with a GIA 75-mm stapler (Fig. 18-14). A 2 silk
suture is attached to the proximal margin, and the specimen
is drawn out into the abdomen (Fig. 18-15). e cervical
end of this tie is fastened to a clamp.
FIGURE 18-11 A Kocher maneuver to mobilize the duodenum and
a pyloromyotomy are performed.
Chapter 18 Surgical Procedures to Resect and Replace the Esophagus 397
FIGURE 18-13 Left cervical incision with the sternocleidomastoid
FIGURE 18-12 Anatomic structures of the left neck below platysma
level. e incision line along the medial border of the sternocleidomastoid muscle is shown. Division of the omohyoid muscle along
with ligation of the middle thyroid vein allows for exposure of the
underlying esophagus.
muscle reected laterally. Finger dissection beneath the omohyoid
muscle develops a plane to the knotted Penrose drain. Inset: e patient
is placed supine for the neck and abdominal incisions (outlined).
e gastric tube is then constructed by resecting the GE
junction and the lesser curvature of the stomach down to
the crow’s foot of veins with a series of thick tissue 75-mm
gastrointestinal anastomosis (GIA) staplers (Fig. 18-16). A
narrow gastric tube is believed to aid in emptying; however,
a diameter of less than 5–6 cm may compromise conduit
perfusion. e right gastric artery along the lesser curvature
can be divided in order to allow elongation of the conduit
(Fig. 18-17). e specimen is removed, and frozen sections
are performed on the margins. Inspection for hemostasis is
FIGURE 18-14 A GIA stapler is used to divide the cervical esophagus. Note the ligated middle thyroid vein and divided omohyoid muscle. Inset:
Traction is placed on the Penrose drain around the cervical esophagus.
398 Part III Esophagus
FIGURE 18-17 e right gastric artery and lesser omentum are
divided with an endostapling device. Inset: A GIA stapler divides the
stomach along the lesser curvature, creating the gastric conduit.
FIGURE 18-15 e specimen is removed through the abdominal
incision with a long heavy silk suture attached to the end of the
esophagus.
FIGURE 18-16 e stomach is mobilized as a pedicle based on the right gastroepiploic vessels. Inset: Incisions illustrated.
Chapter 18 Surgical Procedures to Resect and Replace the Esophagus 399
made of the gastric bed. e esophageal hiatus should admit
four ngers. One ampule of IV glucagons is administered
to ensure relaxation and lengthening of the gastric conduit.
e silk tie that traverses the mediastinum is then attached
to the valved end of a Foley catheter with a 30-cc balloon
(Fig. 18-18). An endoscopic camera bag is secured around
the 30-cc balloon (Fig. 18-19). e conduit is advanced into
the bag, ensuring appropriate orientation. Suction is applied
to the bag via the Foley catheter, and the conduit is drawn
up into the neck incision (Fig. 18–20). e assistant must
actively guide the conduit through the hiatus. At the end, the
pylorus should sit at the hiatus.
e neck anastomosis can be hand-sewn using interrupted full-thickness 3-0 silk sutures (Fig. 18–21). e
anastomosis may also be stapled in side-to-side, functional
end-to-end fashion. A portion of the esophageal staple line is
removed, an enterotomy is created on the posterior aspect of
the gastric tube, and a linear GIA 75-mm stapler is inserted
to create the anastomosis (Fig. 18–22). An additional re of
an endoscopic 30-mm stapler may be used to gain additional
length on the anastomosis. e enterotomy is usually closed
with a TA 30 or 60 stapler after guiding the nasogastric
tube down toward the hiatus. Hybrid anastomosis has been
described with the back wall of the anastomosis created using
a 30-mm stapler and the anterior wall closed with sutures. A
FIGURE 18-19 An arthroscopy camera bag is tied around the Foley
catheter balloon and the gastric conduit is placed in the folded-up
arthroscopy bag ensuring the proper axial orientation. Inset: A
Yankauer suction is attached to the Foley catheter to collapse the bag
around the neoesophagus.
FIGURE 18-18 e heavy silk is tied to the port of a 30-cc balloon
Foley catheter and is pulled up partially through the neck incision.
FIGURE 18-20 e gastric conduit is atraumatically pulled through
the posterior mediastinum into the cervical wound.
400 Part III Esophagus
FIGURE 18-21 e esophagogastric anastomosis is performed with
a single layer of full-thickness interrupted nonabsorbable sutures.
e Silastic sump drain is shown emanating from the fundus of the
gastric conduit. A Jackson-Pratt drain is shown positioned alongside
the gastric conduit inferiorly and exiting from a separate stab wound
above the clavicle.
A
B C
FIGURE 18-22 A. and B. e stapled functional end-to-end
anastomosis is performed using the GIA stapler to approximate the
side of the esophagus to the anterior wall of the stomach. C. e TA
linear stapler is then used to close the defect between the two free
walls.
soft drain should be placed posterior to the anastomosis and
the platysma and skin are closed separately. It is wise to use
an interrupted closure, as this will allow for reopening of a
portion of the wound should a cervical leak develop. Before
closing the abdomen, a J-tube should be inserted at a point
approximately 40 cm distal to the ligament of Treitz. e
fascia is closed using a #2 running monolament suture and
the skin is closed with staples.
Ivor Lewis Technique
e patient is placed in the supine position. Bronchoscopy
to rule out tracheobronchial invasion and esophagoscopy to
conrm the location of the tumor are performed. An upper
midline incision is made from the umbilicus to the xiphoid.
e abdominal phase of this operation is identical to the previously described tri-incisional technique. Enlargement of the
hiatus and dissection of the lower esophagus are more easily
performed through the abdomen than through a high thoracotomy incision. e GE junction and lesser curvature of the
stomach are resected using a GIA stapler. e specimen is left
attached to the esophagus to facilitate mobilization into the
chest. A J-tube is placed before closing the abdomen.
A double-lumen endotracheal tube is placed and the
patient is repositioned in the left lateral decubitus position. A
right posterolateral thoracotomy is performed, and the chest
is entered through the fourth or fth interspace. e azygos
vein is divided and the intrathoracic esophagus is dissected.
All lymphatic tissue is included with the esophagus. Because a
gross margin of 5 cm, and ideally 10 cm, is desired, the anastomosis is usually performed high in the chest at or above the
level of the azygos vein. e proximal esophagus is dissected
only several centimeters above the proposed level of transection to preserve its blood supply. e mobilized stomach is
pulled up into the chest. e anastomosis can be constructed
using an EEA stapler or hand-sewn technique. If a hand-sewn
anastomosis is chosen, a double-layer technique is advisable (Fig. 18-23). In 1942, Churchill and Sweet described a
method of double-layer anastomosis that is still often used
29,30
today.
the staple line is chosen for the anastomosis. A circle of stomach serosa 2 cm in diameter is scored and the underlying gastric vessels are ligated with 4-0 silk sutures. e back outer
layer of the anastomosis is constructed with interrupted 4-0
silk horizontal mattress sutures. ese are placed 4 mm away
from the serosal edge. Full-thickness stomach and esophageal
wall are used. e esophagus is opened with a sharp instrument and the inner layer is constructed with interrupted
suture incorporating esophageal mucosa and full-thickness
stomach edge. e nasogastric tube is passed after completion
of the posterior wall. A continuous Connell suture may also be
used. e anterior outer layer anastomosis is constructed with
4-0 silk horizontal mattress sutures. e anastomosis should
be wrapped or buttressed with omentum. At all times, atraumatic handling of mucosal edges and tying of sutures without
crushing of tissues are advised. Some surgeons advise tacking
A point on the gastric tube at least 2cm away from
Chapter 18 Surgical Procedures to Resect and Replace the Esophagus 401
FIGURE 18-23 View through a right thoracotomy incision showing an esophagogastric end-to-side anastomosis in the apical right chest. Note
the tacking sutures from stomach to the posterior chest wall to avoid torsion.
the edge of the stomach wall to mediastinal tissue or paravertebral fascia to decrease tension on the anastomosis, although
it is not clear if this is necessary. A 28F straight chest tube
is placed into the apex of the chest via a separate stab incision. e chest is closed with interrupted #2 Vicryl paracostal
sutures, followed by a 0 Vicryl running latissimus layer, a 2-0
Vicryl running subdermal layer, and a 3-0 Vicryl subcuticular
layer. Postoperative toilet bronchoscopy should be performed.
Transhiatal Technique
CONSIDERATIONS
We believe that a tri-incisional approach gives better exposure to the thoracic esophagus, allowing for a safer and wider
resection and better lymphadenectomy. As discussed, there
may be survival advantages to the radical resection permitted by the transthoracic technique, although trials to date
have not shown a statistically signicant survival advantage
using this approach. In cases in which the thoracic esophagus
is not involved with tumor (either high-grade dysplasia or a
laryngeal tumor involving the proximal esophagus), the transhiatal technique may be performed with equivalent oncological ecacy.
TECHNIQUE
e patient is placed in the supine position with the head rotated
45 degrees to the right. e abdominal phase of the operation
is performed in identical fashion to that described in the triincisional section above. An upper-hand retractor is useful in
elevating the sternum and costal margin. e phrenoesophageal
ligament is divided using cautery, and the lower esophagus is
encircled with a 1 in wide Penrose drain. e phrenic vein must
rst be identied and ligated. is will also enlarge the window for dissection of the intrathoracic esophagus. e hiatus is
dilated to allow entry of the surgeon’s hand. Arterial branches
from the aorta are clipped on the aortic side and divided using
cautery. in handheld malleable retractors are used to retract
either side of the pleura during the dissection. Dissection under
direct vision is usually possible up to the level of the inferior
pulmonary veins.
At this point, an incision is made in the left neck along the
anterior border of the sternocleidomastoid muscle starting
at the sternal notch and extending 6–8 cm. e platysma is
divided. e sternocleidomastoid muscle and carotid sheath
are retracted laterally. e omohyoid is often divided. e
middle thyroid vein is ligated and divided. A retractor may be
used but must not rest on the recurrent nerve in the tracheoesophageal groove. e esophagus is palpated anterior to the
spine and posterior to the trachea. Sharp dissection is carried
out immediately on the esophagus, separating the esophagus from the membranous trachea and recurrent nerve. e
esophagus is looped with a 1-in Penrose drain.
Blunt dissection of the posterior plane of the esophagus
is performed rst. From the abdomen, the surgeon’s hand is
placed in between the spine and esophagus with the palmar
aspect of the ngertips immediately against the esophagus
(Fig. 18-24). is is performed in conjunction with raising
the esophagus anteriorly with the aid of the Penrose drain.
An identical maneuver is performed through the cervical
incision. When sucient dissection has been done from
either side, both hands are introduced simultaneously and
an attempt is made to touch ngertips. Intervening loose
areolar tissue must then be torn, uniting the ngertips. If the
surgeon’s ngertips will not reach from the neck, a sponge
stick can be used. While the surgeon’s hand is behind the