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384 Left thoracic subtotal esophagectomy
https://t.me/med1917
Based on the anatomy, incision of the
3
diaphragm should preserve the branches of
the phrenic nerve in the diaphragm. For the
transthoracic approach, a radial diaphragmatic
incision between the spleen and the liver is commonly used in our unit. The incision is extended
from the esophageal hiatus through the aponeurotic portion to the muscular portion of the
diaphragm. If the diaphragm is involved by
tumor, the affected portion is resected with the
tumor. In general, the length of the diaphragm
incision is approximately 10 cm, but it can be
extended to 15cm for obese patients, or for large
tumors in the gastric cardia. Traction sutures are
placed through the cut edges of the diaphragm
to aid exposure. The blood vessels in the cut
edges are sutured and ligated. For a combined
thoraco-abdominal approach, the diaphragm is
divided peripherally from its origin on the ribs,
around to the hiatus, leaving the phrenic nerve
undamaged.
3a
Phrenic nerve
Correct incision
Incorrect incision
3b
Operation 385
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Mobilization of the stomach
For gastric mobilization, the essential principles are the
4
preservation of a blood supply by preserving the right
gastric and right gastro-epiploic vessels and arcades and
obtaining maximal length by using the greater curvature for
the positioning of the anastomosis.
Before mobilization of the stomach, the abdominal cavity
is thoroughly inspected. The liver, pancreas and lymph nodes
of the upper abdominal region are inspected and palpated to
determine if potential metastases have occurred to these
organs and tissues.
The initial step in detachment of the stomach is division of
the phrenoesophageal ligament. Next the greater omentum is
divided outside the arch of the gastroepiploic vessels. Care is
taken to preserve the gastroepiploic arcade when separating
the greater omentum and the spleen from the stomach. The
dissection of the greater omentum is carried out to the level of
the pylorus, and the rather small omental branches from the
epiploic vessels are clamped and divided.
The dissection is then directed toward the spleen, where
the left gastroepiploic artery is ligated above its uppermost
branch to the stomach wall. The short gastric arteries are
divided carefully between hemostatic forceps and are ligated
securely. The proximal branches of these vessels may be very
short and require the application of suture ligatures.
Ligatures on the stomach side must be tied securely because
these ties can slip off the stomach if distension of the stomach
in the thorax occurs.
4
Elevation of the stomach to the right by the assistant permits exposure of the left gastric artery and facilitates celiac
lymph node dissection from behind the stomach. Much
attention should be directed toward exposure of the origin
of the left gastric artery at the trifurcation of the celiac axis.
It is necessary to divide the filmy, avascular adhesions
between the back of the stomach and the retroperitoneum.
The left gastric artery is exposed by the surgeon whose
thumb and forefinger encircle the lesser curvature attachments. The fat tissue and lymph nodes around the left gastric artery are dissected carefully, starting from the upper
edge of the pancreas. Then two hemostatic clamps are
applied to the proximal side of the vessel and one to the distal side. The left gastric artery is divided between the second
and third clamps. The left gastric artery is doubly ligated at
its origin from the celiac axis with a heavy nonabsorbable
silk suture. The first ligature is placed and firmly tied proximal to the first clamp, and the clamp is removed. The second tie is then placed on the left gastric artery distal to the
first tie. The artery on the gastric side is best managed with a
secure suture ligature.
386 Left thoracic subtotal esophagectomy
https://t.me/med1917
Lymph nodes and fat tissue along the left gastric artery
5
and around the gastric cardia are dissected to remain
with the resected specimen. For cardia cancer, the transection
of the proximal stomach is performed with a linear stapler,
and the esophagus is mobilized up to the level of the inferior
pulmonary vein. The incision of the stomach is then strengthened with interrupted 4-0 silk sutures placed in the seromuscular layer. For cancer of the esophagus, the stomach itself is
transected at, or just below, the esophagogastric junction.
The stapler is usually used to close the incision of the stomach, and reinforced with interrupted 4-0 silk sutures in the
seromuscular layer. The stump of the esophagus is covered
with a sterilized condom to prevent contamination.
5a
5b
Operation 387
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After completion of the detachment of the stomach and
its transection, further mobilization of the postesophageal
region up to the level of the carina is carried out. Upward lift
of the esophagus by an assistant helps resection of subcarinal
lymph nodes and freeing of the esophagus from the arch of
the azygos vein. Then the total esophagus is pulled to the
supra-aortic arch region. The next step is anastomosis in the
thorax. However, if an anastomosis in the neck is necessary,
the stump of the esophagus is connected to the uppermost
region of the stomach with four interrupted stitches, in order
to aid pulling the stomach into the neck.
HAND-SEWN ANASTOMOSIS
After completion of the mediastinal dissection and
gastric mobilization, the stomach can be brought to any
6
level within the thorax by gentle traction on the upper end of
the greater curvature. This is where the maximal length of the
viscus can be obtained. Traction on the esophageal specimen
upward as a sort of handle permits an end (esophagus)-toside (stomach) esophagogastric anastomosis.
The first row of 4-0 silk sutures is placed in a horizontal
mattress fashion between the muscular layer of the esophagus
and the seromuscular layer of the uppermost stomach wall.
Approximately three or four stitches are placed first. These
form the outer posterior row. At 2.5 cm from the first row of
sutures, an incision of the gastric wall to fit the diameter of
The anastomosis
Although a variety of anastomotic methods have been
reported, these can be classified as hand-sewn anastomoses
and stapled anastomoses (see Chapters 33 and 34). This chapter describes the anastomotic methods most commonly used
in China.
the esophagus is made, and the intramural plexus of vessels is
suture-ligated. Then the sutures forming the first row are tied
carefully by the surgeon, who always draws the stomach
upward to the esophagus by positioning the tying forefinger
above the point of the actual approximation of tissue. The
esophagus is a fixed structure that cannot be brought down
distally; its serosa-less muscular coat is more fragile and does
not hold sutures as well as the stomach. The outer posterior
row of sutures covers about a half of the circumference, and
the corner ties are left long and marked with hemostats. After
completion of the first row of sutures, a soft clamp is applied
proximal to the first row of sutures to stop bleeding from the
upper stump of the esophagus.
The esophagus is transected 3 cm distal to the first row of
sutures and the specimen is removed. Then posterior inner
Uppermost site of
gastric fundus
6a
Transect here
At least 5cm
3 cm
2.5 cm
6b
388 Left thoracic subtotal esophagectomy
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sutures, also 4-0 silk, are placed and tied with care not to cut
the tissue with the suture. Each stitch is placed about 1cm from
the cut margin, and 0.3cm apart from each other. The needle
is pulled through each edge separately, to make sure whole layers of the esophagus and stomach are sutured. The gastric and
esophageal mucosa are picked up with a similar bite of tissue.
When the suture is tied, it is necessary to press the muscular
layer with the tip of a clamp, held by an assistant, to approximate the mucosa of the esophagus and stomach.
The anterior inner row is continued in an interrupted fash-
6c
ion; the stitches are placed and tied as the posterior inner row.
Whole layers of the esophagus and stomach are sutured. The
assistant holds the previous sutures up to facilitate the surgeon placing subsequent stitches. As each suture is tied, the
assistant inverts muscular and mucosal layers into the lumen
when necessary. This method allows complete inversion of
the mucosal layer. This row of sutures is tied from either end
toward the middle so that a final suture can be placed anteriorly, which is an easy way to complete the anterior row. After
all stitches are tied, sutures are then cut.
6e
A nasogastric tube is directed downward through the anastomosis to the level of the gastric antrum and is fixed by the
anesthetist to the patient’s nose to prevent later inadvertent
withdrawal.
The anterior outer row is placed in a horizontal mattress fashion over the remaining half of the circumference of the esophagus. Because the anastomosis has been placed 2.5 cm down
from the apex of the stomach, this row should bring the anterior wall of the stomach up to the same level as the posterior
wall. Three to four horizontal mattress stitches are put between
the muscular layer of the esophagus and the seromuscular layer
of the stomach which brings it upward circumferentially. This
constructs a valve-like luminal orifice which helps to minimize
the possibility of gastroesophageal reflux.
6d
The anterior aspect of the anastomosis may further be buttressed by a flap of omentum, which remains at the upper end
of the gastroepiploic arcade. The stomach is suspended by a
series of nonabsorbable sutures to the fascia that overlies the
thoracic spine. This helps to avoid downward traction on the
anastomosis.
ANASTOMOSIS WITH A CIRCULAR STAPLER
In order to simplify the anastomotic process, an anastomotic
stapler was invented in the former Soviet Union in the 1950s.
Since then, the apparatus has been greatly improved. The currently available circular anastomotic stapler has become safe
and easy to operate.
If an anastomosis using a stapler is planned, the incision
https://t.me/med1917
7
in the stomach is left open after transection at the
esophagogastric junction for the later placement of a stapler.
A purse-string applicator is put on the anticipated site of the
anastomosis in the esophagus. After a purse-string suture is
applied, the esophagus is transected distal to the clamp.
Three Allis forceps are used to grasp the stump of the esophagus at 120 degrees apart after removal of the purse-string
applicator, and the anvil is put into the lumen of the esophagus before the purse-string suture is tied. The head of the
circular stapler is then put into the cavity of the stomach
through the gastric cardia and applied against the gastric
wall at the fundus. The turn button at the distal end of the
stapler is rotated anticlockwise to allow the tip of the central
pole to puncture the gastric wall and connect into the central
pole of the anvil. Then the turn button is rotated clockwise
to approximate the stomach wall to the esophageal stump to
the extent as indicated in the scale plate of the stapler.
Examination of the closed stapler is carried out to make sure
surrounding structures and tissues (including pleura, the
subclavian artery, and foreign bodies such as gauze) have not
been caught. Fire the stapler and turn the turn button anticlockwise. The stapler, with anvil, is pulled out through the
cardia. Check that two complete circular “doughnuts” from
the esophageal and gastric ends are present. If there is any
doubt of the integrity of the doughnuts, the anastomosis is
reinforced with interrupted nonabsorbable sutures. The
incision in the stomach is closed with a linear stapler and
strengthened by oversewing the seromuscular layer with
interrupted 4-0 silk sutures. A nasogastric tube is placed into
the intrathoracic stomach to decrease postoperative gastric
distension.
Operation 389
7a
7b
390 Left thoracic subtotal esophagectomy
https://t.me/med1917
7c 7d
Folding suture of the stomach
https://t.me/med1917
After completion of the anastomosis, the lesser curva-
8
ture of the stomach is oversewn. This minimizes the size
of the intrathoracic stomach and prevents compression of the
stomach on the intrathoracic organs, especially the lung and
heart. Interrupted 4-0 silk sutures are put on the anterior and
posterior walls which are adjacent to the lesser curvature, at
2 cm apart from each other. After each suture is tied, the
stomach is folded in along the lesser curvature.
Operation 391
Closure of the diaphragm incision and the chest
The incision of the diaphragm is closed with 7-0 interrupted
silk sutures and is also sutured to the wall of the stomach with
4-0 thread to prevent prolapse of intra-abdominal contents
into the thorax. The space between the edge of the diaphragm
incision and the stomach should be snug enough to prevent
an index finger passing after completion of the closure of the
diaphragm. The pulse in the right gastroepiploic artery is
checked. A No. 28 Argyle chest catheter is placed through the
eighth intercostal space in the axillary line, for drainage. The
chest wall is closed with interrupted heavy nonabsorbable silk
sutures and careful approximation of the muscles of the chest
wall is undertaken to avoid interference with postoperative
8
shoulder function. Fine interrupted silk sutures are used to
suture the skin.
Left cervical approach
The left thoracic or thoracoabdominal cervical approach is an
additional procedure for the treatment of carcinoma of the
esophagus. The major difference between this method and
the classic left thoracic approach is the level of anastomosis.
For the cancers located in the upper thoracic esophagus, there
is not enough length of normal esophagus to construct an
anastomosis in the thoracic cavity according to oncological
principles. The left cervical approach is therefore carried out
in most of these patients.
392 Left thoracic subtotal esophagectomy
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LEFT NECK INCISION
When the thoracoabdominal incision has been closed the patient is placed in the
9
supine position with a pad under the left shoulder. An oblique incision no more
than 8 cm in length is made along the anterior border of the left sternocleidomastoid
muscle.
The omohyoid muscle is divided together with the middle thyroid vein and the
inferior thyroid artery if these are in the way of the exposure. The carotid artery and
jugular vessels are retracted laterally, and the trachea is retracted medially to expose
the already mobilized esophagus. The esophagus and fundus of the stomach are
delivered through the wound, the stomach being held with a pair of Duval forceps to
prevent it slipping back into the chest.
9a
Sternocleidomastoid
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muscle
Carotid sheath
Operation 393
9b
9c
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