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424 Thoracoscopic management of esophageal diverticulum
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Alternative approach for lower third
(epiphrenic) diverticula
A laparoscopic approach is being used increasingly for
6
diverticula in the lower third of the esophagus (see
“Discussion” below). The mobilization of the esophagus is a
standard approach, as used for antireflux surgery. The only
difference is that the mobilization is taken more proximally in
the mediastinum, and the diverticulum is dissected free in its
entirety. Once again, intraoperative endoscopy is very helpful. A 52 French bougie is then passed and the diverticulectomy is carried out using an Endo GIA. It is usual to require
more than one application of the stapler in order to encompass the whole of the neck of the sac of the diverticulum. As
with the thoracoscopic approach, several tacking sutures of a
fine suture of either prolene or a braided suture are then
inserted to close the muscle defect where the neck of the
diverticulum has been stapled. A myotomy is then carried out
in a different plane from the diverticulectomy, using the same
principles as with the thoracoscopic myotomy. This means
that if the myotomy is taken down through the gastroesophageal junction, a Dor patch is added to the procedure,
but again we believe that it is important to close the longitudinal muscle layer of the esophagus above the Dor patch.
6
DISCUSSION
Esophageal diverticulum is not a common problem, so experience with the minimal approach to its management has
been slow to accumulate. Nevertheless, from reports at recent
international meetings, several points have emerged. First, is
that the procedure seems to be associated with a relatively
high leak rate, and the reason why this leakage rate should be
higher than with open surgery is not clear. Thus, in the largest
experience reported to date in 20 cases there were three staple
line leaks, and at 15% this is a much higher rate than reported
in open series. Other smaller and therefore virtually anecdotal
series have reported even higher leak rates than this. For
instance, our own combined experience of three cases was
associated with two leaks (but no deaths).
Second, there seems to be a move away from the thoracoscopic approach to the laparoscopic approach for distal third
diverticula (which are by far the majority). Dr Peracchia’s
group performed their first ten cases thoracoscopically with
two leaks, and their last ten laparoscopically with one leak.
When a diverticulum is removed at open surgery, the stapler
used is a transverse one which has an extra row of staples
compared to the Endo GIA. Perhaps this is one reason why
the leak rate is lower in the open setting.
For the present, it is clear that the minimal access approach
should only be used with great caution, and with patients
fully informed that the possibility of leakage is probably
higher than with the open approach. Nevertheless, the gains
of minimal access surgery for this condition are so undeniably greater when the patient’s course is uncomplicated that
there seems little doubt the procedure will establish a place in
the treatment of this condition.
FURTHER READING
Fumagalli U, Bona S, Zago M, Bisagni P, Rosati R, Peracchia A.
Laparoscopic approach to epiphrenic esophageal diverticula. V061
ISDE Meeting Sao Paulo, 2001.
41
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Perforation of the esophagus
BAIYA KRISHNADASAN MD
Assistant Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle,
Washington, USA
OLIVIER HUBER MD
Associate Professor, Department of Surgery, University of Geneva; Head, Foregut Surgery, University Hospital of Geneva, Geneva, Switzerland
CARLOS PELLEGRINI MD
The Henry N. Harkins Professor and Chairman, Department of Surgery, University of Washington School of Medicine, Seattle, Washington,
USA
HISTORY
The first reported spontaneous rupture of the esophagus was
described by Herman Boerhaave, a ‘leading physician of the
age,’ in early mid 18th century Germany. His patient, the
Baron de Wassenaer, consumed a large meal and subsequently ‘strove to excite vomiting by tickling his fauces,’
resulting in a post emetic esophageal perforation. Not unexpectedly, the Baron died within 24 hrs, and his post mortem
revealed a linear esophageal perforation that had ruptured
into both pleural spaces. A number of similar reports followed Boerhaave’s seminal description. Attempted suture
repair was only contemplated in the mid 20th century, and
initial attempts in the United States (1944) and England
(1946) were unsuccessful. Successful suture repair was performed by Norman Barrett in 1947, the year following his
insightful and comprehensive review of the subject. Although
post emetic perforation is no longer the principal etiology for
esophageal perforation, it is notable that successful surgical
repair followed two centuries later.
PRINCIPLES AND JUSTIFICATION
Despite improvements in supportive therapies, including
ventilator management, antibiotics and nutrition, perforation of the esophagus can be fatal unless diagnosed promptly
and treated effectively. The most common cause of perforation is passage of instruments down the esophagus, especially
during forced dilatation of an esophageal stricture. Injury to
the cervical esophagus is particularly common following
endoscopy and endotracheal intubation, and these iatrogenic
events account for 60% of cervical perforations. External
trauma due to stab or gunshot wounds is also common in
both the cervical and thoracic esophagus. Other etiologies
include the ‘spontaneous’ or emetogenic disruption of the
esophagus (Boerhaave’s syndrome), perforation of an
esophageal cancer, sloughing of the esophageal wall after
injection sclerotherapy or caustic injury, foreign body
impaction, surgical injury and infectious processes.
A number of recent studies have reported mortality rates of
less than 10% in contrast to the 10–30% historical mortality
from esophageal perforation. These contemporary reviews,
which typically investigate a small group of patients, are predominantly concerned with patients who have had instrumental injury to the esophagus. This cohort of patients
typically have their diagnosis made more expeditiously and
represent a healthier group of patients compared to individuals who have post-emetic esophageal perforation. The current
overall mortality rate for all patients who develop esophageal
perforation is 18%.
The risk of dying from an esophageal perforation varies
markedly with location and extent of the perforation, time
elapsed prior to treatment, the age and general condition of
the patient, and the presence of intrinsic esophageal disease.
A key to understanding the pathophysiology of esophageal
perforation is the recognition that it causes a rapidly evolving
infection of the mediastinum, with substantial spread and
necrosis of poorly vascularized mediastinal fat tissue. In addition, and particularly pertinent to treatment options, there is
prompt deterioration of the esophageal wall at the site of the
rupture. Thus, ideally an esophageal perforation should be
treated within 12 hours of its occurrence – attempts at primary repair after the first 36–48 hours are more challenging.
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Contrast radiography should be used liberally after pneumatic dilatation and whenever the circumstances related to
esophageal instrumentation cause any concern about the
possibility of a perforation.
PREOPERATIVE ASSESSMENT AND
PREPARATION
Clinical diagnosis
The most common symptom is pain, which is first felt during,
or immediately after, the completion of the instrumentation.
Pain is constant, most often radiates to the back, and may be
felt in the upper abdomen and chest, particularly in the case
of thoracic esophageal injury. Perforations in the neck often
present with pain on neck flexion or manipulation of the thyroid cartilage. Subcutaneous emphysema and crepitation are
often evident following cervical perforation and are present
in approximately twenty percent of thoracic esophageal
perforations. Most patients also complain of dysphagia,
odynophagia, occasionally aphagia, and profuse salivation.
Fever and leukocytosis are common within the first 4–6 hours
after perforation and some patients develop hypotension,
sweating, and all the features of shock. Airway compromise is
uncommon following injury to the esophagus, but may be of
concern in the case of a cervical perforation.
The commonly quoted triad of symptoms described by
Mackler, including thoracic pain, following vomiting, associated with cervical emphysema, is only present in approximately 40% of patients. These findings are only relevant to
post emetic esophageal perforation.
1
Radiological diagnosis
Chest and abdominal radiography are invaluable
1, 2
perforation may be suspected from plain films of the neck,
chest, or upper abdomen, as free air may dissect adjacent tissues, creating subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, or even pneumothorax.
Cervical perforation may present with subtle findings such as
air in fascial planes, widening of the retroesophageal space
and loss of normal cervical lordosis. Thoracic perforations
often demonstrate widened mediastinal shadow and air fluid
levels within the mediastinal space. A left pleural effusion is
also an indirect sign of esophageal perforation. In the experience of the authors and of others, however, these signs are
present only in approximately 30% of cases.
in the diagnosis of esophageal perforation. The
2
The essential radiological investigation in these patients
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3
is a contrast study of the esophagus, which will reliably
indicate an esophageal perforation. More importantly, however, contrast studies will define the site and extent of the perforation, the amount of extravasation, the communication
with the pleural or peritoneal cavity, and the presence of distal obstruction. Thus, a contrast study is not only important
to diagnose esophageal perforation but is essential to correct
planning of surgery.
The authors prefer to use meglumine diatrizoate 66%,
sodium diatrizoate 10% (Gastrografin), as the contrast
medium in the initial investigation. This water-soluble material is rapidly absorbed from the gastrointestinal tract and
from the pleural or peritoneal cavity if extravasated. It allows
even small amounts of extravasation to be detected by a
follow-up computed tomographic (CT) scan. Gastrografin
may be more caustic to the airway if aspirated and generates a
false negative study in approximately 20% of cervical
esophageal perforations. In cases where aspiration is a concern or a false negative is suspected, a thin barium swallow
may be more informative.
Preoperative assessment and preparation 427
4
3
CT scanning may detect a small perforation that did not
appear on the esophagogram and is indicated in patients
4
in whom the swallow examination was negative but who are
suspected of having esophageal perforation. Often the CT
scan is the first study that is performed, and may reveal subtle
signs of a perforation, including mediastinal air or fluid, or
small pleural effusion. In these cases the CT scan should be
followed by an appropriate contrast study of the esophagus.
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A CT scan provides invaluable information on patients
5
who present with delayed perforations. These are
patients who survived the initial insult and who have developed an abscess that effectively contains the perforation and
prevents further mediastinal or pleural soiling.
To plan adequate drainage, one must define the site, the
extent, and the relation of the abscess to adjacent structures,
and CT scanning is the test of choice.
Endoscopic diagnosis
Endoscopic examination adds little information to that
gleaned from high-quality contrast radiography. In some
patients, however, particularly those suffering from foreign
body perforation or penetrating trauma, endoscopy may help
to identify and characterize the injury. For example, a patient
who has stab or gunshot wounds may also have a perforated
esophagus. These patients are too unstable to undergo contrast esophagography, and the risk of esophageal perforation
is low. Notably, the sensitivity of esophagoscopy in detecting
subtle injuries is inferior to contrast study and not unexpectedly, it is operator dependent. Another example is a patient
who is undergoing dilatation of an esophageal stricture and
who is suspected of having had a perforation. Insertion of the
endoscope at the end of a difficult procedure may provide
invaluable information at an early stage. It has been recommended that the endoscope be passed through a perforated
esophagus to assess the damage inflicted to adjacent structures, but the authors believe the risks of this maneuver outweigh its potential benefit.
Endoscopic examination may be helpful in those patients
that have intrinsic esophageal disease and esophageal
perforation. In these cases, discovery of a cancer, stricture or
other esophageal pathology, will effect planning of the operation. For this reason, the authors routinely perform
endoscopy on all patients who are undergoing an operation
for esophageal perforation immediately following induction
of anesthesia.
Initial management
The initial management of an esophageal perforation
involves several steps.
AGGRESSIVE RESUSCITATION
These patients suffer rapid dehydration and overwhelming
contamination if the perforation is large and in the chest.
Large bore intravenous access or central access is warranted,
particularly if the patient is being transferred to another
institution. A secure airway is also paramount in elderly
patients requiring large volume resuscitations and who have
compromised ventilation. Occasionally, a chest drain may be
required to drain a pneumothorax or large pleural fluid
collection.
5
ANTIBIOTIC ADMINISTRATION
As soon as a perforation is suspected, the patient should be
started on broad-spectrum antibiotics directed against oral
flora to adequately cover aerobic Gram-positive and Gramnegative bacteria, as well as anaerobic micro-organisms.
Antifungal coverage is also routinely administered at our
institution because of the high incidence of pathologic oral
fungal flora.
ASSESSMENT OF THE INJURY
The surgeon should determine the following before deciding
on the kind of treatment:
1 The type of perforation: ‘contained’ (i.e. limited to the tis-
sue immediately adjacent to the esophagus) or ‘free’ (the
most common type of perforation, with free extravasation
of contents into the neck, the pleural cavity, or the peritoneal cavity)
2 The etiology of the perforation – post instrumentation,
spontaneous, traumatic etc. (The gastroenterologist who
performed the endoscopic procedure that led to the perforation may have important information related to the
esophagus itself and to the injury)
3 The time elapsed since the perforation occurred
4 The location and extent of the perforation
5 The presence of pre-existing esophageal disease, most
commonly an obstruction, usually distal to the perforated
area
6 The age and general health of the patient.
Indications for surgical intervention
The strategy for intervention should be chosen by following
the steps described earlier.
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CONTAINED PERFORATIONS
Contained perforations, which affect a small area of tissue
adjacent to the esophagus, may be treated without surgery,
provided that: (1) the perforation is small; (2) the contrast
material flows immediately back into the esophagus and distally into the stomach; (3) no underlying esophageal disease is
present distal to the perforation (i.e. stricture); and (4) the
clinical manifestations are minimal (i.e. low-grade fever,
minimal pain, etc.). Some have argued that patients that have
had symptoms for greater than 24 hrs or that have eaten following the onset of symptoms should be excluded from this
non-operative approach. It should be noted that this ‘conservative’ management is the exception, not the rule, when treating esophageal perforation. In fact, in some instances the
surgeon ought to look ‘beyond the horizon’ in making the
decision. Such may be the case of a patient who has achalasia
and has a ‘minimal’ perforation. It is unlikely that anyone will
attempt subsequent dilatation of this achalasia; thus, operating early, closing the perforation and performing a myotomy
will deal with both aspects of the problem: the underlying
disease and the complication of treatment.
One perforation that may be treated successfully with conservative (non-operative) management is that which occurs a
few weeks after injection sclerotherapy. The inflammatory
reaction caused by the sclerosing agent adheres the
periesophageal tissues to the wall of the esophagus, effectively
blocking the perforation and decreasing the chance of mediastinal spread of infection. However, the underlying general
state of the patient (cirrhosis) and the esophagus (varices)
would make any attempt at surgical intervention very difficult. When this strategy is followed, the patient should be
given enteral or parenteral nutrition, a nasogastric tube
should be placed with fluoroscopic guidance, broad-spectrum antibiotics should be administered for at least 7 days or
until no sign of infection is present. Most importantly, the
esophagus must be evaluated periodically with contrast radiography and CT scanning to monitor the progress. Any evidence of spread of infection or lack of adequate response to
this treatment should elicit an immediate change of treatment, most probably prompting surgical intervention.
FREE PERFORATIONS
Free perforations, which are much more common than contained perforations, should almost always be treated operatively, regardless of location or size. The principles of surgical
repair include (1) control/drainage of the esophageal leak, (2)
eradication of mediastinal and pleural sepsis, (3) reexpansion
of the lung.
TIME ELAPSED SINCE INJURY
be closed with buttressing. The mediastinal and pleural
spaces should be debrided and drained and the lung decorticated. Patients who present several days after perforation are
likely to have a periesophageal abscess. In these cases closure
of the perforation may no longer be possible; if mediastinal
and pleural sepsis is controlled and the lung is reexpanded,
interventional radiological techniques may be utilized to
drain the infected areas.
LOCATION AND EXTENT OF PERFORATION
Injuries to the esophagus above the thoracic inlet should be
treated by neck incision on the side of the extravasation, or on
the left side (the esophagus is easier to access from the left).
Occasionally, cervical esophageal perforations will extend
into the mediastinum or right chest and require open mediastinal and pleural debridement through a right fifth
intercostal space posterolateral thoracotomy. Nonoperative
treatment of perforations in the neck has been advocated, on
the basis that most heal by apposition of adjacent tissue (no
‘real’ space is present around the esophagus in the neck). The
authors believe that early closure or drainage of these injuries
accelerates recovery and allows for treatment of associated
injuries, which are common when external trauma is the
cause of the perforation. If the perforation has occurred in a
Zenker’s diverticulum, resection of the diverticulum and a
concomitant cricopharyngeal myotomy are recommended.
Most other esophageal perforations should be approached
through a thoracotomy. High and mid esophageal injuries are
best approached by thoracotomy in the right posterolateral
fifth intercostal space. Most low lesions should be approached
through the left posterolateral seventh intercostal space, even
if the extravasation is in the abdomen. Occasionally bilateral
thoracotomies will be required to decorticate both pleural
spaces.
PRESENCE OF UNDERLYING ESOPHAGEAL DISEASE
Underlying esophageal disease plays a critical role in determining the kind of procedure to be performed. Because perforation occurs most commonly during dilatation of strictures,
and because the mechanism of injury is such that the wall of
the esophagus is injured at or just above the stricture, therapy
should be planned accordingly. If the stricture is fixed and
fibrotic, the best treatment is to resect the stricture and perforated area, and immediately reconstruct the gastrointestinal
tract. If the perforation is caused by dilatation for achalasia,
closure of the perforation and a Heller myotomy on the other
side of the esophagus are recommended. Whatever the choice,
the important principle is to never close primarily a perforation above an esophageal stricture.
The time elapsed since the perforation determines to some
extent the intervention to be used. Patients who suffered their
perforation 24–36 hours previously should undergo an
exploration of the area, and if possible, the perforation should
GENERAL HEALTH OF THE PATIENT
Unfortunately, early discovery of a free perforation mandates
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general state of health of the patient, however, may lead to a
decision for nonoperative treatment of a perforation of the
neck or a small mediastinal perforation.
Preoperative preparation
The preoperative preparation involves adequate resuscitation
including tube thoracostomy, antibiotic administration, and
a thorough evaluation of the injury as described earlier.
Anesthesia
During induction of anesthesia, care must be taken to avoid
causing tension pneumothorax, which is possible if vigorous
OPERATIONS
Unobstructed esophagus
Most spontaneous and instrumental perforations occur
6
in the distal esophagus. The best way to approach these
lesions is by thoracotomy through the left posterolateral seventh intercostal space. We routinely harvest an intercostal
muscle flap prior to entering the chest. This pedicle can be
harvested by stripping the periosteum of the seventh and
eighth rib or it can be taken with cautery, with care not to disrupt the underlying neurovascular pedicle. The pedicle is
then wrapped in a warm saline sponge and left in the chest till
it is required during closure of the perforation. Once the chest
has been entered and the lung adequately collapsed, the inferior pulmonary ligament is incised and the lung is packed
into the upper chest. The parietal pleura overlying the esophagus should be opened at a site near the perforation and
extended both cephalad and caudad to permit adequate
exposure. Occasionally the esophageal lesion has lacerated
the pleura, and the site of perforation is obvious from the
beginning. With care taken not to injure the contralateral
mediastinal pleura, the esophagus is dissected off its bed and
surrounded with a one inch Penrose drain above and below
the perforation. The plane of dissection on the esophagus is
on the longitudinal muscular coat and not in the
periesophageal tissue.
Adequate mobilization of the esophagus may require
extensive dissection, particularly if the perforation has
occurred in the right side of the esophagus. The area of injury
must be clearly identified, as well as the normal esophagus
above and below. If the perforation is not evident, the chest
should be filled with saline while the anesthetist blows air
through the esophageal lumen. Bubbles of air will appear at
the site of perforation. Alternatively an endoscope can be
passed transorally and an examination performed while the
mask ventilation is performed before intubation (because of
the hole in the esophagus). The anesthetist must prevent aspiration of blood, secretions, and any residual contrast medium
from the esophagography that may have accumulated in the
esophagus. Inserting a nasogastric tube blindly in these
patients is unwise, as the tube is likely to exit through the perforation and cause further damage. A single lumen endotracheal tube is placed initially to facilitate endoscopy. Finally, a
double-lumen endotracheal tube should be used, as independent ventilation of the lungs is required to be able to collapse the lung on the side of the operation. Appropriate
monitoring and IV access should be ensured prior to induction; liberal use of pulmonary artery catheters and central
venous monitoring is reasonable in elderly or critically ill
patients.
patient is anesthetized and the chest is open. The air insufflated will in most instances be enough to identify the site of
injury but further insight can be gained by directly inspecting
the mucosa. Most often the perforation is easily identified by
surrounding inflammation as well as the presence of
Gastrografin or thin barium in the esophageal lumen. At this
stage a nasogastric tube should be carefully passed transorally
and advanced into the stomach under direct vision to help
during closure of the perforation.
6
Operations 431
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The edges of the perforation are trimmed with scissors to
7
obtain clean edges and to expose the mucosal rent
entirely. Routinely the muscular layer requires additional
debridement and dissection to clearly define the ends of the
mucosal injury. Failure to demonstrate the entire extent of
the mucosal injury will lead to incomplete closure of the
esophageal perforation. If the mucosa is healthy it should be
approximated using an interrupted suture of 3/0 or 4/0
polyglyconate, and the muscular coat closed with interrupted
sutures of nonabsorbable material (3/0 silk or similar). If the
perforation is several hours old and the tissues are edematous,
all the layers may have to be closed together. In this case,
interrupted sutures of nonabsorbable material of adequate
size (2/0 or similar) are preferred, as thinner and monofilament material tends to cut the inflamed tissues.
Interrupted silk sutures
Running mucosal layer
Aorta
Esophagus
7
8
Pleural flap
Esophagus
Whenever possible, the esophageal closure should be
8
buttressed with the previously harvested intercostals flap
or by stripping a flap of pleura from the posterolateral chest
wall. The buttress should be securely sutured to the esophagus to provide an additional layer of tissue to secure the closure. The intercostals flap should be placed parallel and on
top of the repair and sutured to healthy muscular layer with
interrupted 3/0 silk sutures. The pleura may be too edematous to dissect because of the inflammatory reaction. If this is
the case, and if the stomach is accessible, the area may be buttressed using the stomach or omentum.
Finally, any fibrinous membrane and necrotic tissue is
debrided and the lung decorticated. The control of mediastinal and pleural sepsis is a critical aspect of the care of
esophageal perforation, and this aspect of the patient’s operative management cannot be overlooked. The chest is drained
with a large (No. 36) straight tube placed with its tip in the
apex of the pleural cavity and a similar (No. 36) right-angled
tube left on the surface of the diaphragm with its tip near, but
not touching, the area that has been repaired. The proximity
of this chest drain to the repair allows adequate drainage of
the esophagus if the repair is not successful. The chest is then
irrigated and closed. In critically ill patients both gastrostomy
and feeding jejunostomy are performed.
432 Perforation of the esophagus
Esophagus
Perforation closed in two layers
Stomach
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Obstructed esophagus
The two most common conditions are perforation occurring
during pneumatic balloon dilatation of a patient with achalasia and perforation occurring during instrumentation of a
benign or malignant stricture.
PERFORATION FROM PNEUMATIC DILATATION FOR
ACHALASIA
The approach and the initial procedure are similar to that
described for the treatment of the unobstructed esophagus.
This perforation always affects the lower esophagus and is
approached from the left side.
Simply closing the perforation may result in early
9
dehiscence (because of the concomitant obstruction)
and leaves the patient with untreated achalasia. Thus, after
closing the perforation in a manner similar to that described
earlier, the opposite side of the esophagus is exposed, exactly
180 degrees from the perforated area, and a longitudinal
myotomy approximately 6-8 cm along the esophagus is performed. After the phrenoesophageal ligament is divided, the
fundus of the stomach is brought up and the myotomy is
extended one to two centimeters onto the stomach. A partial
fundoplication (Dor, Thal, Belsey) over the area of the perforation is made. The wrap is secured with interrupted sutures
to each side of the myotomy. This not only buttresses the
repair well but also acts as an antireflux procedure and helps
to keep the edges of the myotomy far apart, which prevents it
from healing. The 360 degree plication, as described by
Nissen, should not be used as it is contrary to the principle of
diminishing the lower esophageal sphincter pressure.
PERFORATION ABOVE A FIBROTIC, BENIGN, OR MALIGNANT
STRICTURE
Whenever possible, resection of the esophagus by the transhiatal approach and esophagogastrostomy at the neck are recommended. This treats the perforation and underlying
disease, and brings a graft of well-vascularized tissue into the
9
posterior mediastinum that fills the space and helps treat the
mediastinal infection. The patient is placed in the supine
position, anesthesia is induced, a single lumen tube is used
and both lungs are ventilated. A midline laparotomy is performed and, after a Kocher maneuver, the omentum is
divided outside the gastroepiploic arcade, with care taken to
preserve this arcade.
The gastrohepatic ligament is divided, with the right
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10
tion is then isolated, a tape is passed around the distal esophagus, and the short gastric vessels and the left gastric artery are
divided. The left diaphragmatic vessels are ligated and the
diaphragm is opened anteriorly as far as needed to perform
the mediastinal dissection.
gastric vessels preserved. The gastroesophageal junc-
Right
gastric
artery
Operations 433
Divided short gastric vessels
Divided left
gastric artery
Coeliac
axis
Right
gastroepiploic
vessels
Divided epiploic branches
10
The lower esophagus can usually be dissected under
11
then bluntly to the thoracic inlet. At this stage a pyloroplasty
is performed.
neck following the anterior aspect of the sternocleidomastoid
muscle. The platysma and omohyoid muscle layers are
incised. The sternocleidomastoid and carotid sheath are
retracted laterally and the airway is reflected medially. The
middle thyroid vein is ligated between ties and dissection proceeds just posterior to the prevertebral fascia. Care is taken to
identify and preserve the recurrent laryngeal nerve and to
avoid devascularization of the trachea. Retractors are used
sparingly to preserve the function of the recurrent laryngeal
nerve. Dissection of the esophagus is performed bluntly into
the superior mediastinum after it has been encircled with a
Penrose drain. Using the Penrose drain for gentle countertraction, the esophagus can be bluntly dissected into the
superior mediastinum to the level of the carina.
direct vision to the inferior pulmonary vessels and
A seven centimeter incision is made in the left side of the
11
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