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412 Part III Esophagus
30. Mathisen DJ, Grillo HC, Wilkins EW, Jr, Moncure AC, Hilgenberg
AD. Transthoracic esophagectomy: a safe approach to carcinoma of the
esophagus. Ann orac Surg. 1988;45:137.
31. Orringer M, Marshall B, lannetioni M. Transhiatal esophagectomy:
clinical experience and renements. Ann Surg. 1999;230:392–403.
32. Patil P, Patel S, Desai P. Cancer of the esophagus: esophagogastric
anastomotic leak—a retrospective study of predisposing factors. Surg On-
col. 1992;49:163–167.
33. Law S, Fok M, Chu KM, Wong J. Comparison of hand-sewn and stapled esophagogastric anastomosis after esophageal resection for cancer.
A prospective randomized controlled trial. Ann Surg. 1997;226:169–173.
34. Urschel J. Esophagogastrostomy anastomotic leaks complicating
esophagectomy: a review. Am J Surg. 1995;169:634–639.
35. Honkoop P, Siersema PD, Tilanus HW, et al. Benign anastomotic strictures
after transhiatal esophagectomy and cervical esophagogastrostomy: risk factors and management. J orac Cardiovasc Surg. 1996;111:1141–1146.
36. Swanson SJ, Batirel HF, Bueno R, et al. Transthoracic esophagectomy
with radical mediastinal and abdominal lymph node dissection and
cervical esophagogastrostomy for esophageal carcinoma. Ann orac Surg.
2001;72:1918–1925.
37. Orringer MB, Marshall B, Chang AC, et al. Two thousand transhiatal
esophagectomies: changing trends, lessons learned. Ann Surg. 2007;246(3):
363–372; discussion 372–374.
38. Cope C, Kaiser L. Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42
patients. J Vase Intervent Radiol. 2002;13:1139–1148.
39. Fok M, Cheng S, Wong J. Pyloroplasty versus no drainage in gastric
replacement of the esophagus. Am. J Surg. 1991;162:447–452.
40. Bemelman W, Taat C, Slors F. Delayed postoperative emptying after esophageal resection is dependent on the size of the gastric substitute. J Am Coll
Surg. 1995;180:461–464.
41. Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al. Minimally invasive
esophagectomy: outcomes in 222 patients. Ann Surg. 2003;238(4):486–494;
discussion 494–495.
42. Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and
operative mortality in the United States. N Engl J Med. 2003;349(22):
2117–2127.
43. Dimick JB, Wainess RM, Upchurch GR, Jr, et al. National trends in outcomes for esophageal resection. Ann orac Surg. 2005;79(1):212–216;
discussion 217–218.
VIDEO-ASSISTED THORACIC SURGERY OF THE ESOPHAGUS
Ryan M. Levy • James D. Luketich
INTRODUCTION
Since the initial description of laparoscopic fundoplication
in 1991,
invasive approaches to esophageal disease. While proponents
of minimally invasive surgery claim decreases in perioperative
pain and length of stay, critics often express concerns over
compromised outcomes, prolonged operating times, and
increased cost. However, numerous reports have documented
that for both gastroesophageal (GE) re ux and achalasia,
the laparoscopic approach o ers equal e cacy and safety as
well as decreased recovery times compared with traditional
open surgery. ese reports and the bene ts of minimally
invasive surgery perceived by the general public have increased
referrals to surgeons who o er these approaches to esophageal disorders, even though alternative medical therapies are
available.
conditions involving the distal esophagus and GE junction
are now standard of care, this is not necessarily the case for
minimally invasive approaches to the thoracic esophagus. is
is particularly true for esophageal cancer. Concerns regarding
the high degree of technical complexity, signi cant operator
learning curves, reproducibility of outcomes in lower-volume
centers, and equivalence of oncologic outcomes are at the
forefront of the discussion. Despite evolving techniques and
improvements in both the transhiatal and Ivor Lewis surgical approaches, esophagectomies are complex operations that
are associated with signi cant morbidity and mortality. Furthermore, surgical candidates are often elderly patients with
coexisting medical comorbidities, including respiratory and
cardiovascular diseases. Nationwide, the mortality rates from
esophagectomies range from 8% in high-volume centers to as
high as 23% in low-volume centers.
cases may o er several potential bene ts. First, open esophagectomy, even in experienced centers, continues to be associated with a signi cant morbidity, lengthy hospital stay, and
1
there has been continued interest in minimally
2,
4,
5
Although laparoscopic approaches for many benign
6
e application of minimally invasive surgery to complex
delay in returning to preoperative activities.
plication rate along with the disappointing 25% 5-year survival rate after esophagectomy has led to ongoing concern
over the role of surgery in the treatment of esophageal cancer.
Consequently, for some patients, alternative approaches such
as de nitive chemoradiation alone, palliative photodynamic
therapy, or stents may be chosen by health care providers. Minimally invasive approaches to esophagectomy that promise to
decrease perioperative morbidity and allow for faster postoperative recovery are, therefore, appealing to patients and referring
3
physicians. e caveat, however, is that the minimally invasive
approach should not compromise operative technique or oncologic and functional outcomes.
ere has been a signi cant evolution in technique
since the initial descriptions of hybrid approaches to
esophagectomy that employed thoracoscopic esophageal
mobilization with a laparotomy.
domized studies of minimally invasive esophagectomy
(MIE) have been performed, experience in our rst 222
patients has suggested that MIE is associated with a complication rate and mortality lower than most reports of
open esophagectomy.
invasive approach reduces postoperative pain and pulmonary complications while comparing favorably to the best
published open series with regard to morbidity, mortality,
and oncologic outcomes. In addition, we and others have
shown that minimally invasive staging of esophageal cancer
patients is superior to conventional staging by computed
tomography (CT) and endoscopic ultrasound (EUS)
and may allow for a better selection of patients to receive
combined modality therapy. In this chapter, we review our
experience with minimally invasive surgery for esophageal
cancer, as well as detail surgical techniques for several other
diseases of the thoracic esophagus, such as resection of
benign esophageal tumors and thoracoscopic treatment of
esophageal dysmotility. Laparoscopic approaches to other
complex esophageal operations, including achalasia and
paraesophageal hernia, are covered in Chapters 14 and 15.
19
7
is high com-
8–10
Although no ran-
11
In our experience, a minimally
413
12
414 Part III Esophagus
ESOPHAGEAL CANCER
e optimal management of patients with potentially
resectable esophageal cancer is still evolving. Although surgery remains the standard of care for early disease, several
studies have suggested that denitive chemoradiation may
be an acceptable alternative. is position is supported by
the results of a randomized, prospective trial conducted by
the Radiation erapy Oncology Group (RTOG 8501),
which compared denitive chemoradiation versus radiation
therapy alone for patients with locally advanced esophageal
13
cancer, who were not considered surgical candidates.
e
study was closed after accrual of 121 patients, due to a clear
survival benet in the combined treatment group. e surprising nding in this study was that the 5-year survival in the
chemoradiation group was 27%, a rate not appreciably dierent from the survival rates following esophagectomy alone.
14
Additional support for the use of chemoradiation for esophageal cancer comes from the results of two, large prospective
European studies. In these studies, chemoradiation followed
15,16
by surgery was compared to chemoradiation alone.
In
both studies, overall survival was equivalent between the
two treatment arms. Chemoradiation with surgery decreased
locoregional recurrence within 2 years of surgery. However,
with chemoradiation alone, treatment-related mortality was
decreased and hospital stays were shorter.
15,16
ese reports have led some clinicians to recommend
nonoperative therapy for marginal surgical candidates, such
as the elderly or those with multiple comorbidities. Indeed,
the National Comprehensive Cancer Network now considers
denitive chemoradiation to be an acceptable alternative to
17
esophagectomy in their recent guidelines.
It is incumbent
upon esophageal surgeons, therefore, to continue to rene the
technique of esophagectomy, in order to oer therapy with
either lower morbidity, improved survival, or both compared
to traditional esophagectomy and other approaches.
Staging for Esophageal Cancer
Unlike lung cancer, in which mediastinoscopy is an accepted
and proven staging technique, no invasive modality is considered standard for staging patients with esophageal cancer.
However, to date none of the noninvasive staging techniques
currently available, such as CT, EUS, or positron emission
tomography (PET), has proven accurate enough to preclude
the need for invasive staging. A recent evidence-based review
concluded that there exists a benet for laparoscopic staging
of esophageal cancer based on level 2 evidence, showing a
sensitivity of 71 and 78% for detection of peritoneal and
nodal metastasis, respectively.
and exceeded sensitivities for endoscopic ultrasound and
CT imaging.
e current noninvasive technology suers from several,
well-described limitations. CT, often the initial staging test performed for patients with esophageal cancer, is an appropriate
18
is compared favorably
tool to screen for distant disease, such as pulmonary or liver
metastases. However, even in this role, occult metastatic disease is missed by CT scans in up to 15–20% of patients.
19
Furthermore, CT is clearly unable to provide sucient anatomic detail to either accurately stage the depth of invasion of
the esophageal wall or determine the presence of local nodal
involvement. Indeed, the accuracy of CT scanning for nodal
disease is only 45–60% in most series.
20,21
PET scanning is a recently introduced technology that
is based on imaging the dierential uptake of radio-labeled
glucose by malignant and normal cells. PET scanning has
been extensively studied in the context of both lung and
esophageal cancer. Indeed in some centers, PET scanning
has become a routine component of the preoperative evaluation of lung cancer patients. is practice is justied by
several meta- analyses that have demonstrated the superiority
of PET over CT in staging nodal disease in the mediasti-
22,23
num.
However, equal ecacy for PET scanning has not
been demonstrated for esophageal cancer patients. We have
found the accuracy of PET scanning to assess locoregional
lymph nodes in patients with esophageal cancer to be only
24
about 50%.
e specicity is improved, compared to CT,
but the sensitivity remains poor. In our experience PET scanning has been more useful in detecting distant metastatic
disease. In a series of 100 consecutive patients with potentially resectable esophageal cancer staged at our institution
by PET and CT, PET identied metastatic disease in 16%
25
of patients missed by CT.
e false-negative rate for PET
in this series was only 10% and usually occurred in cases of
subcentimeter disease that was below the detection threshold
of PET scans.
Another staging tool available in specialized centers is EUS.
Although EUS is operator dependent, in experienced hands
its accuracy for assessing T stage is greater than 90%, and it
26
has an image resolution of 0.2 mm.
e accuracy of determining T stage increases with penetration of the esophageal
wall: the accuracy for T1 tumors is 80%, T2 tumors 90%,
27
and T3/4 tumors 95%.
However, the accuracy of EUS to
determine nodal status is far lower than its ability to determine tumor depth and has been reported to be 65–86%.
12,28
Technique of Minimally Invasive
Surgical Staging
Currently, all patients at the University of Pittsburgh with a
diagnosis of esophageal cancer undergo noninvasive staging
with CT scans, PET scanning, and EUS. If any of these studies
indicates metastatic disease or nodal involvement (in the case
of EUS), a needle biopsy is performed. If distant metastatic
disease is proven, palliative options are generally pursued. For
patients without proven metastatic disease and GE junction
tumors, we then, generally, proceed to laparoscopic staging.
Laparoscopic staging is performed with the patient in a steep
reverse Trendelenburg position with thesurgeon standing on
the patient’s right side.
Chapter 19 Video-Assisted oracic Surgery of the Esophagus 415
OPERATIVE STEPS OF MINIMALLY INVASIVE
STAGING—LAPAROSCOPY
1. An initial 10-mm blunt trocar is placed via an open,
cut-down technique in the right epigastrium. e location of this port is approximately 3 cm to the right of
the junction between the lower and middle third of a
line connecting the xiphoid and umbilicus. After the rst
port is placed, a visual assessment is made of the liver and
peritoneal surfaces, and, if obvious metastatic disease is
present, biopsy conrmation is obtained and the staging
is complete. If no metastatic disease is seen on this initial
survey, a more thorough staging is performed with placement of additional port sites. ese are placed in the same
locations utilized for MIE.
2. e ve ports generally include one 10-mm blunt cut-down
port just to the patient’s right of midline, midway between
the xiphoid and umbilicus (for the surgeon’s right hand
instruments), one 10-mm port at the same level to the left
of midline for the laparoscope, two additional 5-mm ports
along the right costal margin (for liver retraction and dissection), and one 5-mm port on the left costal margin for
countertraction by the assistant (Fig. 19-1). e liver surfaces are carefully examined and any abnormalities biopsied.
Ultrasound examination of the liver may then be performed,
although in our experience, the yield of ultrasound examination in patients who do not have some visual evidence of
liver metastases is low.
19
3. e stomach is carefully assessed for gastric extension of
the tumor to determine the suitability of the stomach for
gastric pull-up.
4. Nodal assessment is initiated by incising the gastrohepatic ligament. e lesser sac is entered, and nodes along
the lesser curve and at the base of the celiac artery are
sampled.
5. We have been evaluating preoperative “conditioning”
of the esophagus. is may be performed at the time of
laparoscopic staging and includes lymph node dissection of the left gastric artery and vein and division with
an Autosuture Endo GIA stapler (Covidien, Manseld,
MA) with a vascular load. We also divide the short gastric
vessels from the left crus to the right gastroepiploic arcade.
6. At the conclusion of the staging procedure, a laparoscopic
feeding tube may be placed. However, we have found that,
in most cases, dysphagia will respond to chemotherapy,
rendering a feeding tube unnecessary. If chemotherapy is
planned, an Infusaport is placed at the time of staging.
If the patient has no metastatic disease and minimal or
no nodal disease is apparent on laparoscopy, we proceed to
MIE. We have not found routine thoracoscopic staging to
be very benecial for most adenocarcinomas of the distal
esophagus. oracoscopy is used selectively for tumors of
the midthoracic esophagus, once laparoscopic staging has
excluded gross intra-abdominal disease. is practice is based
on our prospective series of 53 patients all of whom underwent both laparoscopic and thoracoscopic staging. Of the 36
patients with adenocarcinoma of the GE junction, those who
were identied as node-positive using minimally invasive
12
staging, 31 were identied by laparoscopy.
If thoracoscopy
is indicated, the approach is normally through the right chest,
although a left-sided approach may be appropriate if suspicious pulmonary lesions are identied on that side.
5 mm
10 mm
5 mm
FIGURE 19-1 Abdominal port placement for staging laparoscopy
and totally minimally invasive Ivor Lewis esophagectomy.
5 mm
10 mm
OPERATIVE STEPS OF MINIMALLY INVASIVE
STAGING—THORACOSCOPY
1. Five ports are used for access and placed as depicted
inFig. 19-2.
2. e initial step is to mobilize the inferior pulmonary
ligament and to sample the level 9 nodes.
3. Next, the pleura overlying the lower third of the esophagus
is opened. Once this plane is developed, nodes from the
periesophageal (level 8) and subcarinal stations (level 7) may
be harvested. Lymph node dissection is continued until a
positive node is found or an adequate sampling indicates
benign nodes only.
Two large, prospective studies have investigated the
benets of minimally invasive staging for esophageal cancer.
e rst, from our institution, showed signicant advantages
416 Part III Esophagus
10 mm
5 mm
5 mm
10 mm
10 mm
FIGURE 19-2 oracoscopic port placement for staging and totally
minimally invasive Ivor Lewis esophagectomy.
for minimally invasive staging compared with more standard
modalities.
and concurrent laparoscopy and thoracoscopy. Forty-seven
patients also underwent endoscopic ultrasound. e
sensitivities of CT and EUS to document nodal metastases
were only 33 and 63%, respectively. Even when these two
modalities were combined, inaccuracies in staging were seen
in 32% of cases, compared with minimally invasive staging.
Only two complications were seen in this series: a prolonged
air leakand a port site hernia that was repaired on the rst
postoperative day.
e second study, comprising 134 patients, was a multiinstitution, National Cancer Institute (NCI)–sponsored study
designed to determine the feasibility of minimally invasive
staging.
as documentation of T4 or M1 disease, the procurement of at
least one abdominal and three thoracic lymph nodes, or one
node that documented metastatic disease. Minimally invasive
staging was successful in 73% of patients and was performed
with no mortality and only minimal morbidity. Noninvasive
tests, such as CT and EUS, failed to identify positive lymph
nodes documented by minimally invasive staging in 20%
of patients. Unfortunately, the true sensitivity of minimally
invasive staging was not determined by this study because
12
All 53 patients in this report underwent CT
29
Successful minimally invasive staging was dened
the majority of patients underwent induction chemotherapy
prior to resection.
Ultimately the role of minimally invasive staging
should be claried by clinical trials that demonstrate a
survival advantage for patients with node-positive disease
who receive induction therapy. To date, most randomized
trials have had signicant limitations and demonstrated
30
marginal benets for preoperative chemoradiation.
However, the poor survival obtained after surgery alone ensures
that the neoadjuvant approach will continue to be investigated. We believe that a signicant limitation of the
studies performed to date is that patients have not been
accurately staged prior to undergoing combined modality
therapy. Accurate staging may identify a subpopulation of
patients who would benet from such aggressive treatment,
and studies not designed for subgroup analysis may report
false-negative conclusions.
Molecular Staging of Esophageal Cancer
It is estimated that between 30 and 50% of patients who
are staged as node-negative by routine histological evaluation following esophagectomy will develop a recurrence of
31
their disease.
is suggests that these patients harbored
micrometastatic disease that was undetected by routine
histology. In an attempt to improve the staging of these
patients, we have used minimally invasive staging to obtain
lymph nodes that are evaluated with molecular biology
techniques, such as reverse transcription polymerase chain
reaction (RT-PCR), to determine the presence of micro-
32
metastases.
were histologically staged as node-negative.
We evaluated nodes from 30 patients who
33
Of these
30 patients, 11 were identied by RT-PCR as harboring
micrometastatic disease. Furthermore, the quantitative
expression of carcinoembryonic antigen by RT-PCR was
a powerful, independent predictor of disease recurrence
and death. We believe that these techniques may identify
patients with early-stage disease who have a high risk of
recurrence and may benet from additional therapy.
Minimally Invasive Esophagectomy
e technique of minimally invasive esophagectomy (MIE)
that has evolved as our experience with other minimally
invasive foregut procedures, such as laparoscopic Heller’s
myotomy, repair of giant paraesophageal hernia, and staging
for esophageal cancer, has grown. At present, minimally invasive techniques for esophagectomy include laparoscopic transhiatal, laparoscopic-thoracoscopic three-hole (McKeown),
and laparoscopic-thoracoscopic (Ivor Lewis) esophagectomy.
Each of these can be performed with lymph node sampling
or a more complete lymph node dissection. While the choice
between approaches is to a large degree based on surgeon preference, the operative approach is at times dictated by anatomic
location of the tumor margins.
Chapter 19 Video-Assisted oracic Surgery of the Esophagus 417
Initial attempts at MIE were hybrid operations combining
traditional open surgery with minimally invasive techniques.
One of the rst reports by Collard et al in 1993 included
12 patients who underwent thoracoscopic mobilization of
the esophagus followed by laparotomy and preparation of
9
the gastric conduit.
In that series, two patients required
conversion to thoracotomy for bleeding. Several subsequent
reports have demonstrated the feasibility of this approach;
however no denitive benet has been shown compared to
open esophagectomy.
34–36
A completely laparoscopic transhiatal esophagectomy
has also been described. e largest series, published by
37
DePaula et al in 1995,
described 48 patients who required
esophagectomy predominantly for end-stage achalasia secondary to Chagas’ disease. Only two patients required conversion to laparotomy. Early experience with MIE in the
United States was reported in 1997, when Swanstrom and
Hansen described a carefully selected group of nine patients
with small tumors, benign strictures, and Barrett’s disease.
38
Eight of these patients had a totally laparoscopic transhiatal
video-assisted thoracoscopic surgery (VATS) procedure.
Similar to these early reports, our initial eorts at MIE
were with the transhiatal approach. Advantages of a totally
laparoscopic approach include single patient positioning
and no need for single-lung ventilation. However, we found
that the disadvantages of this approach were signicant.
e small working space through the hiatus allowed limited
access to the middle and upper third of the esophagus and
made any thoracic lymph node dissection extremely dicult. Because of this, we added a right VATS to mobilize the
thoracic esophagus followed by laparoscopy to prepare the
gastric tube. To date, we have performed over 1000 MIEs
at the University of Pittsburgh Medical Center. For the
majority of our initial experience, we utilized a three-hole
laparoscopic-thoracoscopic approach. In our earlier publications with this technique, we demonstrated that MIE could
be performed safely with equivalent stage-specic survival as
compared to the larger open series in the existing literature.
11
ough technically demanding and associated with a signicant operator learning curve, data from our series revealed
a decrease in operative blood loss, length of stay, pulmonary complications, and narcotic requirements. In both our
own experience and publications elsewhere, concerns arose
regarding an increased incidence of technical complications
associated with cervical esophagogastric anastomosis, including anastomotic leak, stricture, recurrent laryngeal nerve
injury, and pharyngoesophageal swallowing dysfunction.
39–41
In light of these concerns and the dominance of GE junction cancers in our current referral pattern, our technique
has evolved to a completely laparoscopic-thoracoscopic (Ivor
Lewis) esophagectomy with complete lymph node dissection. Unless contraindicated by tumor location or previous
thoracic surgery, we presently favor the totally minimally
invasive Ivor Lewis approach.
e main criteria favoring the Ivor Lewis approach include
the following: (1) e surgical margin aorded by the Ivor
Lewis approach is adequate for almost all GE junction tumors.
(2) e technical experience of most training programs in
thoracic and general surgery residencies is in the abdomen
and chest and not in the neck. (3) e morbidity of recurrent laryngeal nerve injury is as high as 20–30% with neck
anastomosis. (4) e length of gastric conduit needed to reach
the neck may be up to 10 cm longer than that needed for
an intrathoracic esophagogastric anastomosis. (5) Although
easier management of leaks through the neck incision may be
considered an advantage of cervical anastomoses, leaks from
the neck may still drain into the chest after laparoscopicthoracoscopic three-hole (McKeown) techniques especially
when a narrow gastric conduit is constructed.
Early in our experience, MIE was only oered to patients
with Barrett’s disease and early-stage tumors; however, we now
oer MIE to patients with more advanced disease. Patients
found to have bulky celiac nodal metastases by CT or staging
laparoscopy are not felt to be immediate candidates for MIE,
and consideration is given to an open operation, a neoadjuvant protocol, or denitive chemoradiation.
Operative Technique
As previously mentioned, our preferred approach has evolved
to a totally minimally invasive laparoscopic-thoracoscopic
(Ivor Lewis) esophagectomy. e patient is positioned supine
on the operating room table with a foot board in place. A
double-lumen endotracheal tube is placed for single-lung ventilation during the thoracoscopic portion of the procedure.
e laparoscopic portion of the procedure is performed rst.
LAPAROSCOPIC PHASE
1. e initial step of MIE is an on-table esophagogas-
troduodenoscopy (EGD) to conrm the precise location of the tumor, evaluate proximal and distal extent
with careful attention to involvement of the cardia,
and assess the suitability of the stomach as a conduit
for reconstruction. It is important to minimize insufation during the endoscopy as overdistention of the
small bowel can complicate the laparoscopic phase of
the procedure.
2. e laparoscopic portion of the procedure is then
initiated. e surgeon stands on the right side and the
assistant on the left. Five ports (three of 5 mm and two
of 10 mm) are placed, similar to the staging procedure
(see Fig. 19-1). Initially, we place the 10-mm port via a
cut-down technique approximately 3 cm to the right of
the junction between the lower and middle third of a line
connecting the xiphoid and umbilicus. Carbon dioxide
insuation is utilized for pneumoperitoneum to a pressure of 15 mm Hg. e remaining ports are then placed:
5cm to the left of the operating port (30-degree camera
port), subcostal on the right and left midclavicular lines
(tissue grasper ports), and in the right ank (liver retractor port). If clinically indicated, we then perform laparo-
418 Part III Esophagus
Division of gastrohepatic &
Division of
phrenoesophageal ligaments
FIGURE 19-3 Initial dissection, division of gastrohepatic ligament
and crura, hiatal mobilization.
scopic staging as described previously. is lower position
of the ports may make the hiatal dissection somewhat
dicult but greatly facilitates the mobilization of the gastric tube. is emphasizes the importance of completely
mobilizing the esophagus and any hiatal hernia sac circumferentially during the thoracoscopic dissection.
3. e gastrohepatic ligament (lesser omentum) is rst
divided and the right and left crura of the diaphragm
are dissected to mobilize the lateral wall of the esophagus (Fig. 19-3). Care is taken not to divide the phrenoesophageal membrane at this point so as to prevent loss
of pneumoperitoneum into the chest cavity. e left
gastric artery/vein pedicle is identied, and by tracing
its course proximally the celiac lymph nodes are then
examined. A complete lymph node dissection is carried
out to include the celiac nodes, sweeping all nodal and
fatty tissue with the specimen; the nodal dissection is
later continued along the splenic artery and the superior
border of the pancreas during gastric mobilization. is
plane continues cephalad toward the right and left crus,
continuous with the preaortic dissection plane into the
lower thoracic cavity. All lymph nodes are removed, and
any lymph nodes suspicious for metastatic involvement
are dissected and sent for frozen-section analysis.
4. Gastric mobilization (Fig. 19-4). e dissection is then
carried anteriorly and superiorly over the esophagus to
nally expose the anterior hiatus. As the dissection is
continued toward the left crus, the fundus of the stomach begins to be mobilized. e medial border of the
right crus is dissected inferiorly until the decussation
of the right and left crural bers, thereby exposing a
retroesophageal window and completing the mobilization of the superior portion of the lesser curvature and
GE junction. e greater curvature of the stomach is
gastrosplenic lig
& short gastric
vessels
FIGURE 19-4 Gastric mobilization. (Modied from Tsai WS, Levy RM,
Luketich JD. Technique of minimally invasive Ivor Lewis esophagectomy. Op Techn
orac Cardiovasc Surg. 2009;14:176–192. Copyright 2009, with permission from
Elsevier.)
then mobilized by rst dividing the short gastric vessels,
followed by division of the gastrocolic omentum while
carefully preserving the right gastroepiploic arcade (see
Fig. 19-4). We utilize either the ultrasonic shears such
as Autosonix (Covidien, Manseld, MA) or the LigaSure device (Valleylab, Boulder, CO). Occasionally, clips
will be required during division of large-diameter, short
gastric vessels. Recently, on the basis of published data
42
and personal communication (Dr Earl Wilkins), we
have selectively utilized an omental pedicle wrap of the
intrathoracic esophagogastric anastomosis. At this point
in the operation, we mobilize a long, narrow tongue of
omentum from the middle to upper third of the greater
curvature. We attempt to base this omental pedicle o
of two feeding vessels to ensure viability (Fig. 19-5).
After the gastrocolic omentum is identied, the antrum
of the stomach is retracted and a window is created in
the greater omentum, thus allowing access to the lesser
sac. Dissection is carried along the greater curve of the
stomach until the end of the gastroepiploic arcade is
reached. During this mobilization, it is important to be
constantly mindful of the location of the right gastroepiploic vessel.
5. e mobilized stomach is retracted superiorly, and
any remaining adhesions between the posterior wall of
the stomach and the pancreas are divided as well. e
left gastric vessels are then identied, dissected, and
Chapter 19 Video-Assisted oracic Surgery of the Esophagus 419
Pyloroplasty
ere are often signicant adhesions in the retroantral
and periduodenal regions that also need to be dissected
to allow for adequate mobilization of the inferior portion
of the stomach. Particular attention to mobilization of
the pyloric antral area is needed in patients who have had
prior cholecystectomy. Adequate mobilization is evident
when the pylorus can be gently lifted up to the level of
the right crus in a tension-free manner. is may require a
partial or complete Kocher maneuver. Two traction sutures
are placed at the edges of the pylorus with the 2-0 Endo
Stitch (US Surgical, Norwalk, CT). e pyloroplasty is
performed by incising the pylorus longitudinally with the
FIGURE 19-5 Creation of omental pedicle ap.
ultrasonic shears and closing it transversely with interrupted sutures using the Endo Stitch device in a HeinekeMikulicz fashion. is usually requires four to ve sutures.
Prior to completing the abdominal portion of the proce-
divided with a vascular load of the stapler. is is done
by approaching the pedicle from the lesser curve. Prior
to division, a complete celiac lymph node dissection
is performed, continuing along the superior border
of the splenic artery and pancreas toward the splenic
hilum. Adherence to oncologic principles is important
at this step, so the pedicle should be dissected completely clean with all celiac and left gastric nodes swept
up into the specimen.
6. Attention is then turned to mobilization of the pyloric
antral area and subsequent pyloroplasty (Fig. 19-6).
dure, a tongue of omentum is mobilized to fashion an
omental patch that is sutured to the pyloroplasty site.
7. Creation of the gastric tube. All tubes previously in
the stomach or esophagus are pulled back. A 4- to
5-cm-diameter gastric conduit is then constructed using
multiple res of the stapler (4.8 mm) beginning from
the lesser curve antral area, just proximal to the pylorus and heading toward the angle of His (Figs. 19-7 and
19-8). It is essential to avoid excessive manipulation and
resulting trauma to the gastric conduit during all steps.
To facilitate exposure, staple alignment, and conduit
incision
Pyloroplasty closed
transversely with
auto suture device
Pyloroplasty
A B
FIGURE 19-6 Creation of the laparoscopic pyloroplasty.
420 Part III Esophagus
Surgical
Tumor
specimen
Gentle
traction
Divided
left gastric
Gentle
traction
5 cm
Creation of
gastric tube
Division
parallel to
greater
curvature
FIGURE 19-7 A vascular stapler is red across the lesser curvature near the incisura to begin formation of the gastric tube.
Pyloroplasty
FIGURE 19-8 Completion of gastric tube construction.
Surgical
specimen
Gastric tube
Chapter 19 Video-Assisted oracic Surgery of the Esophagus 421
30 cm distal
length during this step, we have found it helpful to have
the assistant gently lift the greater curve of the stomach,
along the line of the proximal short gastric arteries and
retract gently toward the spleen. Simultaneously, another
assistant grasps the antrum and retracts inferiorly. is is
accomplished through an additional 12-mm port placed
in the right lower quadrant to assist with the creation
of the gastrictube. is essentially elongates the entire
stomach and provides the alignment necessary to construct a consistent diameter gastric conduit without spiraling. e rst stapler used for this is a vascular load to
control bleeding from the adipose tissue and vessels along
the lesser curve. e stapler is placed just up to, but not
onto, the gastric antrum as this tends to be thicker tissue.
e initial 12-mm right midclavicular port is changed to
a 15-mm port to allow for the placement of a 4.8-mm
Endo GIA stapler. Creation of the gastric tube is then
started by dividing the stomach at the lower end of the
lesser curve near the incisura using a vascular load (2.5mm) stapler, with care being taken to preserve the main
right gastric vessels and one or two of the rst branches
entering the antral area. e stomach is rst divided
across the antrum with 4.8-mm staple loads. Because
this region of the stomach is generally quite thick and
muscular, larger staples are required to secure its closure.
Early in our experience, we discovered that very narrow
gastric conduits (2–3 cm in diameter) were associated
with increased gastric tip necrosis and anastomotic leaks,
and therefore we now construct wider conduits measuring about 4–5 cm in diameter. Once the thicker antrum
has been divided, the operating port is changed back to
an 11-mm port and the fundus is divided using a 3.5mm stapler. As the fundus is divided, the graspers are
readjusted to keep the stomach constantly stretched. If
there is extension of tumor onto the gastric cardia, a
wider margin is left in this region.
8. Feeding jejunostomy. Under direct vision, a jejunostomy
catheter (10F) is then placed using the Seldinger technique
as depicted in Fig. 19-9. e patient is placed in the Trendelenburg position with the transverse colon and greater
omentum retracted cranially. e 12-mm, previously
placed, right lower quadrant port is used as the operating
port while the right upper quadrant epigastric port is used
for the camera to facilitate this maneuver. e ligament of
Treitz is identied, and approximately 30cm distal to this
point, a suitable limb of proximal jejunum is tacked to the
lateral, anterior abdominal wall in the left midquadrant
with a single 2-0 Endo Stitch. Under direct visualization,
a jejunostomy catheter (Compat Biosystems, Minneapolis,
MN) is then placed, with intraluminal position conrmed
by distending the jejunum with 10 mL of air insuated
via the catheter. e jejunum is then securely tacked to the
abdominal wall at the catheter entry site with a purse-string
type circumferential tacking stitch using a 2-0 Surgidac
Endo Stitch. A second simple 2-0 Surgidac Endo Stitch
is placed 3 cm distal to the catheter insertion site so as to
prevent torsion and possible strangulation around a single
xed point (see Fig. 19-9).
9. e tip of the gastric conduit is then secured to the specimen with 2-0 Endo Stitch (Fig 19-10). During this step,
care is taken to maintain alignment so that subsequent
retrieval of the specimen through the hiatus into the chest
does not lead to any rotation and maintains perfect anatomic alignment of the gastric conduit with the short gastrics facing the direction of the spleen and the lesser curve
staple line facing the right chest. With our recent use of
omental pedicles, we have also started tacking the omental
pedicle wrap to the proximal end of the conduit so as to
FIGURE 19-9 Feeding jejunostomy.
to ligament of
Treitz
One additional
suture placed
into peritoneal wall
20 cm distance
into jejunum