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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter • Minimally Invasive Esophagectomy
Laparoscopic Phase
Positioning and laparoscopic port placement
e patient is positioned supine with the arms out at a 60°. A foot board is placed to allow steep
reverse Trendelenburg positioning during the hiatal dissection. e costal margin is identied
and a line is drawn from the xiphoid to the umbilicus. is line is then divided into thirds. e
rst port is placed using a direct Hassan cutdown approach in the right paramedian position
roughly 2 cm lateral to the midline at the junction of the lower and middle thirds of the described
line. A total of ve abdominal ports are used for gastric mobilization (12-mm right and le paramedian, 5-mm right and le subcostal, and a second 5-mm right lateral subcostal port for liver
retraction; .
port is placed in the right paraumbilical region to assist in placement of the feeding jejunostomy
tube. All ports should be a hand’s breadth apart so as to avoid interference between instruments.
In addition, it is important to keep skin and fascial incisions small so as to avoid subcutaneous
emphysema.
While working at the hiatus, the camera is placed in the le paramedian port position. e
surgeon works from the right side of the table using the right paramedian and subcostal ports.
e assistant, on the le of the table, controls the camera as well as a second grasper for retraction (through the le subcostal port). e liver retractor is brought in through the right lateral
subcostal port and positioned to elevate the le lobe of the liver and expose the hiatus.
Fig. 15.1
) with the remaining ports placed under direct laparoscopic vision. A sixth
. Fig.15.1
Gastric mobilization
orough inspection of the abdomen is performed to ensure that no injuries were caused during
the process of port placement and to evaluate for intraperitoneal metastasis. e peritoneal lining,
omentum, and liver are visually inspected for abnormalities with biopsies taken of any suspicious
lesions for frozen-section evaluation. e gastrohepatic ligament is opened and the le gastric
vascular pedicle identied (
leaving the le gastric and celiac lymph nodes with the specimen. is dissection is continued
laterally along the splenic artery and the superior border of the pancreas and superiorly toward
the crura along the preaortic plane. If there is a question of potential malignant involvement,
these nodes are sent for frozen-section evaluation to aid in determination of resectability. Once
ensured that no nodal disease is present, the right crus is dissected, allowing lateral mobilization
of the esophagus. is dissection is continued anterior to the esophagus, transecting the phrenoesophageal ligaments and exposing the anterior hiatus. e le crus may be exposed either by the
continuation of this anterior dissection along the medial crural border or by rst mobilizing the
fundus of the stomach by division of the short gastric vessels. Dissection of the le crus is continued posteriorly until the decussation of the right and le crural bers is noted. is exposes the
retroesophageal window and ensures complete mobilization of the superior portion of the lesser
curvature and gastroesophageal junction.
. Fig. 15.2). A complete lymph node dissection is then performed,
Section II • Esophagus, Stomach, and Duodenum
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Aer identifying the gastrocolic omentum, the antrum of the stomach is retracted, and a
window is created in the greater omentum, thus allowing access to the lesser sac. e remaining
short gastric vessels are divided, taking care to preserve the right gastroepiploic arcade. e fundus
is retracted to the right and this dissection is continued posteriorly, eventually exposing the le
gastric artery and vein and joining the lesser curve dissection plane to complete mobilization of the
stomach. Gastric mobilization is carried inferiorly to the pyloroantral region. Meticulous attention
must be paid during this phase of the dissection because any injury to the gastroepiploic arcade
at this level may render the gastric conduit unusable. is dissection may be especially dicult
in patients who have had pancreatitis or a history of prior biliary surgery. Adequate mobilization
has been achieved when the pylorus is able to reach the level of the caudate lobe of the liver, which
may require either a partial or a complete Kocher maneuver. e le gastric artery and vein are
then divided using an endovascular GIA stapler. Care should be taken to ensure that all nodes are
swept toward the specimen side and to avoid narrowing of the splenic or hepatic arteries.
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. Fig.15.2
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Chapter • Minimally Invasive Esophagectomy
Creation of the gastric tube
e gastric tube is created prior to the completion of the pyloroplasty and placement of the feeding
jejunostomy tube to allow for an assessment of the viability of the gastric conduit. e gastric tube
follows the arc of the greater curve of the stomach and is based on the right gastroepiploic artery
(
. Fig. 15.3). An endovascular stapling technique allows for a controlled creation of the gastric tube
conduit. e rst staple load is placed across the adipose tissue and vessels along the lesser curve,
above the level of the right gastric artery. No stomach is divided in this initial staple ring, which
is intended to provide hemostasis. e subsequent staple rings divide stomach. We prefer 45-mm
staple loads for this process (purple loads; Endo GIA Reloads with Tri-staple Technology, Covidien,
Manseld, MA) because the course of the greater curvature can be followed more precisely, result
ing in improved conduit length. An additional grasper is brought through the right paraumbilical
ort at this time to assist in the retraction of the stomach during creation of the gastric tube. It is
p
important to keep the stomach on stretch during this process so as to create a straight conduit. e
rst assistant grasps the tip of the fundus along the greater curve and gently stretches it toward
the spleen. A second instrument from the paraumbilical port grasps the antral area with a slight
downward retraction. e stomach is rst horizontally divided across the antrum. e staple line
is then directed superiorly, toward the fundus, parallel to the line of the greater curve. A conduit
width of 4 to 5 cm is preserved (.
concern for extension of the tumor onto the gastric cardia. Sutures may be placed to reinforce the
staple line if there is concern about its integrity, although this practice is not routinely necessary.
Fig. 15.4
). e length of the conduit is shortened if there is
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. Fig.15.3
. Fig.15.4
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Section II • Esophagus, Stomach, and Duodenum
Pyloroplasty
e pylorus is visually identied and 2-0Surgidac (Covidien, Manseld, MA) stay sutures are
placed on the superior and inferior aspects using the Endostitch device (U.S. Surgical, Norwalk,
CT) to place it on stretch (
ultrasonic shears. e pyloromyotomy is then closed transversely in a Heineke-Mikulicz fashion
using simple, interrupted 2-0Surgidac sutures. An omental patch (with a vascular pedicle if the
patient received neoadjuvant treatment) is placed over the pyloroplasty prior to termination of
the abdominal portion of the operation.
. Fig. 15.5). e anterior wall of the pylorus is then transected with an
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. Fig.15.5
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Feeding jejunostomy tube placement
A 10-French jejunostomy catheter is placed in the le lower quadrant using a percutaneous technique (
. Fig. 15.6). e transverse colon is retracted superiorly to expose the ligament of Treitz
and a position in the jejunum is identied 30 to 40 cm from this location. e antimesenteric
border of the bowel is sutured to the abdominal wall with a 2-0Surgidac suture. e 12-mm right
paraumbilical port is used by the surgeon with the camera positioned in the right paramedian
location. A Seldinger technique is then used to introduce the catheter into the jejunum under di-
Chapter • Minimally Invasive Esophagectomy
rect laparoscopic vision. Air insuation via the catheter can be used to verify luminal placement.
e jejunum is then tacked to the abdominal wall anterior to the catheter entry site to prevent
leakage, and an additional suture to the abdominal wall is placed in the distal limb of jejunum to
prevent rotation and obstruction.
. Fig.15.6
Preparation for thoracoscopic phase
e gastric conduit is again assessed for viability and, if needed, resection of the nonviable portion
and further mobilization with extension of the Kocher maneuver are performed at this time. Once
viability of the conduit is ensured, the most superior portion of the gastric tube is stitched to the
specimen (.
avoided as the stomach is brought into the chest. We ensure this by suturing the greater curvature
along the short gastric vessels to the staple line of the proximal gastric remnant. If an omental ap
has been created, the distal end is sutured to the conduit tip. Clips are applied to the staple line as
needed for hemostasis. e specimen and gastric conduit are then placed in the lower mediastinum, again taking care to preserve the proper orientation of the gastric conduit (.
hiatal opening appears large, the crura are reapproximated with a stitch to prevent delayed thoracic
herniation of the conduit. A nasogastric tube is then placed in the esophagus for decompression
in preparation for the thoracic phase of the operation.
Fig. 15.7
). It is imperative to maintain the alignment of the conduit so that twisting is
Fig. 15.8
). If the
. Fig.15.7
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Section II • Esophagus, Stomach, and Duodenum
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. Fig.15.8
Thoracoscopic Phase
Positioning and Port Placement
e patient is placed in the le lateral decubitus position and the placement of the double-lumen
endotracheal tube is endoscopically reconrmed. e operating surgeon stands on the right side
of the table (facing the patient’s back) while the assistant stands on the le side of the table. A total
of ve thoracoscopic ports are used (. Fig. 15.9). A 10-mm camera port is placed in the eighth
or ninth intercostal space, just anterior to the midaxillary line. e working port is a 10-mm port
placed in the eighth or ninth intercostal space, posterior to the posterior axillary line. Another
10-mm port is placed in the anterior axillary line at the fourth intercostal space, through which a
fan-shaped retractor aids in retracting the lung to expose the esophagus. A 5-mm port is placed
just inferior to the tip of the scapula for the surgeon’s le hand. A nal 5-mm port is placed at the
sixth rib, at the anterior axillary line for suction by the assistant.
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. Fig.15.9
Chapter • Minimally Invasive Esophagectomy
Thoracoscopic dissection and resection of the esophagogastric specimen
Adequate retraction of the diaphragm is essential to the thoracoscopic phase of the dissection.
A 48-inch, 0Surgidac suture is placed through the central tendon of the diaphragm using the
Endostitch. e suture is brought out through the lateral chest wall at the level of the insertion
of the diaphragm through a small stab incision, retracting the diaphragm inferiorly and exposing the distal esophagus. e inferior pulmonary ligament is divided to the level of the inferior
p
ulmonary vein to allow for maximal retraction to the lung. is dissection is carried onto the
avascular plane along the surface of the pericardium, which becomes the medial border of the
dissection. is dissection is carried superiorly to the subcarinal space, with the lymph nodes kept
en bloc with the esophagus (. Fig. 15.10). Care must be taken to identify the membranous wall
of the right mainstem bronchus because it is easily injured during this phase of the dissection.
Removing any suction from the right lung during this dissection will prevent the membranous
wall from collapsing and can aid in visualization. e lung is then retracted anteriorly and the
pleura incised along the anterior border of the esophagus to the level of the azygos vein. e
azygos vein and vagus nerve are divided to facilitate the dissection and prevent traction injuries
to the recurrent laryngeal nerve during esophageal mobilization. Above the level of the azygos
vein, dissection is kept close to the esophagus to avoid injury to the recurrent nerves. e ex
tent of superior dissection and mobilization depends upon the location of the tumor and the
in
tended site of resection. To facilitate lateral mobilization, the pleura is divided in the groove
posterior to the esophagus. is dissection is kept supercial to avoid injury to the thoracic duct
and underlying thoracic aorta. Bridging lymphatics and aortoesophageal vessels are controlled
with endoclips and subsequently divided with the ultrasonic shears. A careful thoracic duct
ligation should be considered if there is concern for trauma to the duct. is lateral dissection
is carried along the length of the esophagus from above the azygos vein to the level of the gastroesophageal junction. e contralateral pleura marks the deep margin of the dissection. e
le p
drain to encircle the esophagus can also be useful to provide traction and elevate the esophagus
from the mediastinal bed.
Once the esophagus has been completely mobilized, the specimen and attached gastric conduit
are delivered into the chest, preserving the orientation of the gastric tube. e conduit staple line
should be directly facing the lateral chest wall. e stitch between the specimen and the conduit
is cut and the tip of the conduit secured to the diaphragm with an Endostitch to prevent it from
retracting into the abdomen. e specimen is then retracted anteriorly and superiorly, away from
the esophageal bed, and the dissection completed along the contralateral pleural surface. Above the
level of the azygos vein, this dissection again moves to the plane along the wall of the esophagus
itself to avoid recurrent laryngeal nerve injury. Lymph node sampling is not routinely performed
at this level.
Once mobilization of the esophagus is complete, a 4- to 5-cm minithoracotomy is made
between the surgeon’s working port and the tip of the scapula. A wound retractor (Applied Medical, Rancho Santa Margarita, CA) is placed to protect the skin and chest wall. e esophagus
is then sharply transected using laparoscopic scissors at or above the level of the azygos vein as
determined by the proximal extent of tumor. e nasogastric tube is pulled back into the proximal esophagus under direct vision as this is done. e esophagogastrectomy specimen is then
w
ithdrawn through the wound protector and sent for frozen section evaluation of the resection
margins.
leural space may be entered if needed to remove a bulky tumor. e insertion of a Penrose
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Section II • Esophagus, Stomach, and Duodenum
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. Fig.15.10
Creation of the gastroesophageal anastomosis
Attention is next turned to construction of the esophagogastric anastomosis. Our preferred technique utilizes an end-to-end anastomosis (EEA) stapling device (.
pler is placed in the cut proximal end of the esophagus and secured in place with two pursestring
sutures of 2-0Surgidac. All layers of the esophagus must be included in the suture to ensure a
competent anastomosis. Typically, a 28-mm EEA stapler can be used without diculty. is size
will help to minimize stricture formation and potentially decreases the need for postoperative
dilation. If the proximal esophagus does not appear large enough to accommodate the 28-mm
anvil, a Foley catheter can be used to gently dilate the esophageal lumen in an attempt to facilitate
placement of the anvil before electing a smaller stapler size. e gastric conduit is pulled further
into the chest and the tip of the gastric conduit is opened using ultrasonic shears to the right side
of the staple line. e EEA stapler is placed through the wound protector and positioned through
the gastrotomy inside the conduit. e stapler spike is brought out along the greater curve of the
gastric conduit to dock with the anvil. Prior to creating the anastomosis, we carefully estimate the
amount of conduit that will lie in the chest. It is a common mistake to bring an excess stomach into
the chest with the intent of minimizing tension on the anastomosis. A redundant conduit above
the diaphragm can lead to signicant problems with conduit emptying. In addition, ensuring
proper orientation of the stomach is critical to prevent twisting. e stapler is then opened two
complete turns and withdrawn. e tissue rings are inspected to ensure that they are complete
prior to proceeding further.
Fig. 15.11
). e anvil of the sta-
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Chapter • Minimally Invasive Esophagectomy
. Fig.15.11
Aer stapling, the remaining excess gastric tip, including the gastrotomy through which the stapler
was introduced, is resected with two or three loads of the endovascular GIA stapler (.
If an omental ap was created during the abdominal dissection, it is wrapped around the anastomosis and secured in place with two or three sutures. e chest is then thoroughly irrigated and
inspected for hemostasis. Final anatomy of the reconstruction is demonstrated in
Fig. 15.12
. Figure 15.13.
).
. Fig.15.12
. Fig.15.13
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Section II • Esophagus, Stomach, and Duodenum
Drain placement and closure
Adequate drainage of the mediastinum and the area surrounding the anastomosis is imperative
to mitigate complications related to anastomotic leak. A 10-mm Jackson-Pratt drain is placed
posteriorly along the anastomosis and a 28-French chest tube is directed posteriorly toward the
apex. e previously placed nasogastric tube is advanced past the anastomosis under thoracoscopic
visualization. e gastric conduit is sutured to the right crus with a single 2-0Endostitch to prevent
torsion or delayed herniation of the conduit. A long aspirating needle is used to instill a multilevel
intercostal nerve block to aid in postoperative pain control. e minithoracotomy is closed using
pericostal sutures with a multilayer so tissue closure. e Jackson-Pratt drain is secured with
multiple sutures to prevent it from becoming dislodged. Once the patient is turned to the supine
position, the oropharynx and nasopharynx are suctioned free of all secretions. e double-lumen
endotracheal tube is withdrawn and the patient reintubated with a single-lumen endotracheal tube.
Use of a tube exchange catheter should be discouraged because this device is placed blindly and may
cause injury to the right mainstem bronchus, which is potentially vulnerable owing to the dissection
of the thoracic esophagus. A toilet bronchoscopy is then performed using an adult bronchoscope.
At this time, both right and le mainstem bronchi are examined for any evidence of airway injury.
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Postoperative Care
Patients are taken to the intensive care unit postoperatively and typically remain there for the rst
postoperative day before transferring to the surgical oor. e typical hospital stay is 7days in
patients with an uncomplicated postoperative course. e nasogastric tube may be removed on
day2 and “trickle” (20–30 mL/h) jejunostomy tube feeds are started. A contrast esophagram is
obtained on day3 to 4 if the patient has adequate pulmonary toilet and a good cough. If there is
no evidence of leak, oral intake is initiated in the form of1 to 2 oz of clear liquids per hour. is
is advanced over 2days to full liquids, no more than3 to 4 oz/h along with cycled tube feeds. e
chest tube is removed when output low (< 150 mL/day) and the clinical course negative for leak.
e Jackson-Pratt drain is pulled back3 to 5 cm on postoperative day5 and resecured. e drain
is removed at the rst postoperative clinic visit in 2weeks’ time.
Postoperative Complications
Early complications
Anastomotic leak
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Anastomotic dehiscence
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Conduit necrosis
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Bowel obstruction
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Ileus
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Chylothorax
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Pleural eusion
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Recurrent laryngeal nerve injury: vocal fold paresis/paralysis
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Pneumonia
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Respiratory failure
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Pleural space infection
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Late complications
Stricture
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Bile reux
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Poor conduit function (dilation, herniation, tortuosity)
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Recurrent cancer
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Weight loss
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Aspiration
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