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472 Atlas of Gastrointestinal Surgery: Esophagus
This usually requires three firings of the stapler. Care is taken not to make the
gastric tube too wide. The points of division along the greater and lesser curva-
tures of the stomach are chosen to provide an adequate distal tumor margin of at
least 5 cm from the gastroesophageal junction. The staple line on the stomach is rein-
forced with an interrupted layer of 3-0 silk Lembert sutures (16).
16
Staple line
oversewn
The esophagogastrostomy is performed with two layers of interrupted 3-0 silk
sutures. The site of the anastomosis on the stomach is placed down from the most
cephalad portion of the fundus and midway between the staple line and the greater
curvature on the anterior wall. The posterior outer layer of interrupted 3-0 silk
sutures is placed first (17). A gastrotomy is performed cutting out a 1- to
1.5-cm elliptical button of the stomach using electrocautery on low voltage. The posterior wall of the esophagus is divided, preserving as much
of the mucosal layer as possible (18). The sutures of the inner layer of
the posterior row pass through and through the full thickness of both the
gastric and esophageal walls (19).
Once the inner layer of the posterior row has been placed, the remain-
ing esophagus is divided and the specimen removed from the operative field.
At this point, frozen sections can be performed on both the proximal and distal
margins. The nasogastric tube is passed into the stomach. The inner layer of the ante-
Fundus
Neoplasm
Proximal
esophagus
Distal
esophagus
Outer layer
of posterior
row placed
17
Fundus
Oversewn
staple line
rior row is performed with an
interrupted inverting suture that
passes from inside out on the
Outer layer
of posterior
row placed
Esophagogastrectomy: Separate Abdominal and Thoracic Incisioins 473
Inner layer of
posterior row
esophageal wall, and then outside in on the gastric wall (20).
The anastomosis is completed by
placing the outer layer of the
anterior row with interrupted 30 silk Lembert sutures (21).
The tip of the fundus is the most
ischemic part of the conduit. To
help minimize leaks in this area, a
purse-string suture is placed circumferentially (22), and once
tied, the tip is inverted and the
purse-string is secured (23).
Distal
Proximal
18 19
Outer layer of
anterior row
Inner layer of
anterior row
20
Tip of fundus inverted
22
21
23
474 Atlas of Gastrointestinal Surgery: Esophagus
The anastomosis can be wrapped either with a piece of parietal pleura based on a long
pedicle or, alternatively, with any redundant stomach, like a Nissen fundoplication (24).
Mediastinal lymph nodes are either sampled or a complete dissection performed. The stomach is sutured to the enlarged hiatus with interrupted 3-0 silk. A chest tube is inserted, and
the incision closed in layers.
Fundoplication
Hiatus
Nasogastric
tube
24
Esophagogastrectomy through a Left
Thoracoabdominal Incision
Operative Indications
In contrast to the esophagogastrectomy (described in the previous section) performed through separate abdominal and thoracic incisions, an esophagogastrectomy can be performed through one incision utilizing the thoracoabdominal approach.
One has to be certain that the malignancy is confined to the area of the gastroesophageal junction. With this approach,
the proximal extent of the esophageal resection is restricted by the aortic arch. If, however, after radiographic studies and
endoscopic biopsies, it is certain that the neoplasm is confined to the distal esophagus without submucosal spread and
without Barrett’s mucosa extending proximally, the thoracoabdominal incision can be used. This approach is perhaps best
suited for gastric cancers near the gastroesophageal junction that extend up into the distal esophagus.
Operative Technique
The patient is placed in a left thoracotomy position, with the hips rotated back
toward the table at a 45˚ angle, to provide access to the abdomen. The left
pleural cavity is entered through the seventh or eighth interspace; the incision
extends across the abdomen to a point midway between the xiphoid and umbili-
cus. If preoperative staging has left some uncertainty as to the resectability of the
lesion, the abdominal portion of the incision can be made first; the abdomen is
explored with the hand before deciding whether to open the entire thoracoabdominal incision.
The costal cartilage is divided, removing a section of cartilage so that chon-
dritis is not a problem when the ribs are subsequently re-approximated.
476 Atlas of Gastrointestinal Surgery: Esophagus
Diaphragm viewed from above
Radial
incision
1a
Esophagus
Circumferential
incision
Left phrenic n.
Aorta
Inferior
vena
cava
1b
Once the chest and abdomen have been opened, it is necessary to divide the diaphragm in order to provide appropriate
exposure to mobilize the colon. Whereas many surgeons divide the diaphragm radially (1a), extending the incision toward
but not through the esophageal hiatus, fewer branches of the phrenic nerve are divided if the diaphragm is opened circumferentially (1b). When the latter is done, it is important to leave at least 3 cm of diaphragm attached to the chest wall,
to facilitate approximation during closure.
Once the abdomen and chest have been opened, the esophagus in the chest is mobilized and encircled with a Penrose
drain. The esophageal hiatus is dissected and widened, and the gastroesophageal junction, distal esophagus, and tumor are
extensively mobilized. The left gastric vessels along the lesser curvature and the vasa brevia along the greater curvature are
divided. The retroperitoneal portion of the fundus of the stomach and distal esophagus is mobilized. Through the abdominal incision the greater omentum is divided, leaving the right gastroepiploic vessels intact. The fundus is divided using the
linear stapler, taking several applications. The line of division is chosen to ensure an adequate distal tumor margin of at least
5 cm. The staple line in the distal stomach is reinforced with an interrupted layer of 3-0 silk Lembert sutures (2). A
pyloromyotomy or pyloroplasty is performed, as described in “Short Segment Colon Interposition for Benign Esophageal
Stricture” above.
The proximal fundus, gastroesophageal junction, distal esophagus, and tumor are retracted up through the hiatus into
the chest. The proximal stomach is also pulled through the hiatus into the chest (3).
Pyloroplasty
Stomach mobilized
and divided
Esophagogastrectomy through a Left Thoracoabdominal Incision 477
Liver
Diaphragm
retracted
cephalad
Fundus
Heart
Staple line
reinforced
2
Tumor
Esophagus
Stomach pulled
into chest
Diaphragm
retracted
caudad
3
Proximal
fundus
Esophagus
Widened
hiatus
478 Atlas of Gastrointestinal Surgery: Esophagus
Outer layer of
posterior row
Esophagus
4
Neoplasm
Proximal
fundus
The esophagogastrostomy is performed with two
layers of interrupted 3-0 silk. The site of the anastomosis on the stomach is placed down from the most
cephalad portion of the fundus and midway between
the staple line and the greater curvature on the anterior wall. The posterior outer layer of interrupted 30 silk sutures is placed first (4). A gastrotomy is
performed, cutting out a 1- to 1.5-cm elliptical button of the stomach using electrocautery on low voltage. The posterior wall of the esophagus is divided,
preserving as much of the mucosal layer as possible
(5). The sutures of the inner layer of the posterior
row pass through and through full thickness of both
the gastric and esophageal walls (6).
5
Gastrotomy
Esophagotomy
Inner layer of
posterior row
6
Specimen
removed
Once the inner layer of the posterior row has
been placed, the remaining esophagus is divided and
the specimen removed from the operative field. At
this point, frozen sections can be performed on both
Esophagogastrectomy through a Left Thoracoabdominal Incision 479
the proximal and distal margins. The nasogastric tube
is passed into the stomach. The inner layer of the
anterior row is performed with interrupted inverting
sutures that pass from inside out on the esophageal
wall, and then outside in on the gastric wall (7). The
anastomosis is completed by placing the outer layer
of the anterior row, with interrupted 3-0 silk
Lembert sutures (8). A purse-string is placed circumferentially around the tip of the fundus so that
this potentially ischemic portion of the conduit can
be inverted, and the purse-string is secured.
Alternatively, if this portion of the conduit is well
vascularized, it can be wrapped around the
esophageal anastomosis creating a Nissen-type fun-
Inner layer of
anterior row
7
Outer layer of
anterior row
doplication. The stomach is tacked to the widened
hiatus with 3-0 silk sutures. A feeding jejunostomy
is placed as described in “Esophagogastrectomy:
Separate Abdominal and Thoracic Incisions” above.
A chest tube is placed, and the diaphragm and chest
closed in layers.
8
Transhiatal Blunt Esophagectomy
with Esophagogastrostomy
Operative Indications
Patients with neoplasms along the entire length of the esophagus (1) are candidates for transhiatal blunt esophagectomy
with a cervical esophagogastrostomy, as long as the tumor does not extend into the mediastinum, pericardium, aorta or trachea, rendering blunt dissection not only impossible, but also dangerous. In addition, the procedure is not possible if the
tumor extends so far onto the stomach that, after the resection, there is not enough stomach to reach into the neck for an
anastomosis. The operative procedure is particularly well suited for patients who are not in ideal shape nutritionally, and/or
have pulmonary disease. Such patients do not readily tolerate both an abdominal and thoracic incision. The operation is
done through an abdominal and a cervical incision, thus obviating
the need for a thoracotomy. Added advantages of transhiatal blunt
esophagectomy over the standard esophageal resection, done
through a thoracoabdominal or separate abdominal and thoracic
incisions, are that single lung isolation is not required and that the
anastomosis is done in the neck. Thus a leak is not nearly as catastrophic as if the anastomosis had been performed in the chest. If
mediastinal involvement is evident on CT scan or if
tracheal/bronchial involvement is evident on CT scan or endoscopy,
blunt esophagectomy should not be performed. Patients with
benign esophageal disease are also candidates for transhiatal blunt
esophagectomy. Many surgeons, however, prefer to reconstruct the
esophagus with a long segment of colon when the esophagectomy
is done for benign disease.
1
Tumor
Transhiatal Blunt Esophagectomy with Esophagogastrostomy 481
Operative Technique
The patient is placed in the supine position. The abdomen, anterior chest, and left
neck are prepped and draped appropriately, with the head turned to the right. The
abdomen is opened first through an upper midline incision. The initial part of this procedure is identical to that of esophagogastrectomy done through separate abdominal
and chest incisions. The abdomen is explored to be certain that widely disseminated
tumor is not present, thus obviating the indication for esophagectomy.
The intra-abdominal esophagus is mobilized, and the esophageal hiatus dilated.
The vasa brevia are ligated and divided (2). Clips are avoided on the stomach
because they may come off when the stomach is subsequently advanced through the
Neoplasm
Esophageal
hiatus
dilated
posterior mediastinum. The greater omentum is divided, carefully preserving
the right gastroepiploic vessels and the entire gastroepiploic arch. The
2
gastrohepatic ligament is divided, and the left gastric vessels are
dissected free both anteriorly and posteriorly through the lesser
sac. The left gastric vessels are ligated close to their takeoff
Vasa brevia
divided
from the celiac axis and divided (3).
3
Stomach
reflected
cephalad
Left gastric
vessels
divided
Greater omentum
divided
preserving
gastroepiploic
arch