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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана
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Fig. 14 Passage of the
delivery tube through the
proximal esophageal stump
for anvil placement using
the OrVil device (A
esophageal stump, B
delivery tubing)
M. Jureller et al.
Orvil anvil (OrVil, Autosuture, Norwalk, CT, USA), which is a device that mounts
the anvil on a 90-cm long polyvinyl chloride delivery tube. The delivery tube is
passed transorally, similar to a nasogastric tube, and advanced into the remaining
proximal esophagus. A small opening is made in the center of the staple line of the
divided esophageal stump and the delivery tube is pulled distally until the anvil shaft
protrudes through the esophagotomy and the anvil head is seated in the distal stump
(Fig.14). The delivery tube is detached by cutting the securing stich and the tube is
removed. The gastric conduit is then pulled up further into the chest to assure that it
will reach the proximal esophagus. The tip of the conduit is opened parallel to the
staple line enough to allow the head of a 25-mm EEA stapler (EEA XL 25-mm with
4.8-mm staples, autosuture, Norwalk, CT, USA) to be inserted (Fig.15). Once the
stapler head has been inserted into the gastrotomy, the conduit is pulled onto the
stapler for a few centimeters. It is important to avoid twisting of the conduit once the
stapler head is inserted, keeping the staple line to the patient’s right (Fig.15). The
stapler pin is then brought out through the wall of the conduit opposite the staple
line and docked with the anvil (Fig.16). The stapler is red after making sure surrounding tissue has been cleared. Once the stapler has been removed, two complete
anastomotic rings (one from the esophagus side and the other from the gastric side)
should be removed from the stapler. This creates an end (esophagus) to side (conduit) anastomosis, which avoids using the gastric conduit tip (which is usually
slightly ischemic). The excess conduit is then resected with a linear stapler, making
sure to avoid crossing of the staple lines (Fig.17). The gastric conduit should appear
well perfused and appropriately oriented with the staple line facing the surgeon
(Fig.18). Alternatively, the esophagus can be transected with scissors and a 25-mm
or 28-mm EEA stapler anvil is placed into the esophagus and secured with two
purse string sutures. All layers of the esophagus, including the mucosa, should be
incorporated into the purse string. Once the anvil is secured, the end-to-side esophagogastric anastomosis is completed, as described above.
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Fig. 15 The gastric
conduit is pulled up into
the chest and opened along
the staple line at the tip (a)
the conduit is oriented with
the staple line to the
patient’s right (facing the
surgeon) (b) the EEA
stapler head is then
inserted into the conduit
lumen (c) and the conduit
is pulled up onto the
stapler neck (d)
a
b
c
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M. Jureller et al.
Fig. 15 (continued)
Fig. 16 The pin of the
EEA stapler is brought out
the side of the gastric
conduit opposite the staple
line and docked with the
anvil that has been seated
in the proximal esophageal
stump (A gastric conduit, B
EEA stapler pin, C anvil, D
proximal esophageal
stump)
d
Fig. 17 Once the
end-to-side
esophagogastric
anastomosis is completed,
the excess conduit/conduit
tip is resected, making sure
not to cross the staple lines
(A excess conduit/conduit
tip, B gastric conduit, C
esophagogastric
anastomosis, D proximal
esophagus)
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Fig. 18 Complete
end-to-side, intrathoracic
esophagogastric
anastomosis (A spine, B
gastric conduit, C airway)
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12 Operative Techniques
Throughout the last century, a number of esophagectomy techniques have been
popularized, including Transhiatal, Ivor Lewis, McKeown (or 3-hole), Sweet (or
thoracoabdominal) and Minimally Invasive Esophagectomy (MIE) techniques.
Signicant controversy persists regarding which open approach is best. The MIE
has been developed over the last two decades, but its denition remains vague (i.e.
hybrid, hand-assisted, laparoscopic, thoracoscopic, and robotic techniques), making
comparison with open approaches difcult. Factors to consider when deciding
between these operative strategies include surgeon experience, tumor location, pulmonary reserve, history of previous operations, indication (malignant or benign
pathology), and availability of conduit for reconstruction. The basic principles and
steps of each approach were reviewed previously. The steps specic to each technique and the strengths/weaknesses of each are discussed in the following section.
13 Ivor Lewis Esophagectomy (ILE)
The ILE consists of an upper midline laparotomy followed by repositioning and
right thoracotomy for resection and reconstruction with an intrathoracic anastomosis. With the patient supine, the abdominal stage is performed rst. After ruling out
metastatic disease, the stomach is mobilized, the left gastric is pedicle divided and
celiac lymphadenectomy are performed, the gastric conduit is created, and adjunct
procedures (i.e. pyloroplasty and J-tube) completed. The tip of the conduit is
attached to the specimen for later retrieval in the chest. The abdomen is closed and
the patient is repositioned in the left lateral decubitus position. Single-lung ventilation is initiated (a double-lumen endotracheal tube or bronchial blocker is required
to isolate the right lung). Following right thoracotomy, the intrathoracic esophagus
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is mobilized and mediastinal lymphadenectomy is performed. The conduit is then
pulled up into the chest, the esophagus is transected proximal to the disease, and the
specimen is removed. The intrathoracic esophagogastric anastomosis is then performed. After the chest has been washed out, drains/chest tubes are placed and the
chest is closed.
ILE is an ideal operative strategy for mid-esophageal and distal esophageal
tumors, as this approach allows excellent visualization for complete mobilization of
the esophagus and lymphadenectomy. The number of lymph nodes harvested tends
to be greater with a thoracic approach and the risk of vocal cord paralysis is lower
by avoiding the neck dissection needed for a cervical anastomosis [7, 19].
Anastomotic leaks are less common, presumably due to less tension on the intrathoracic anastomosis in comparison to a cervical anastomosis where the conduit must
be pulled up for a greater distance [19, 20]. Historically, intrathoracic anastomotic
leaks tended to result in greater morbidity due to associated mediastinal sepsis or
empyema. However, appropriately placed drains and percutaneous drainage techniques have resulted in less morbidity from intrathoracic leaks in the current era.
Pulmonary complications and more postoperative pain are the primary negatives of
the ILE, attributed mainly to the thoracotomy.
M. Jureller et al.
14 Transhiatal Esophagectomy (THE)
THE can be performed via robotic/laparoscopic approach or laparotomy along with
a left neck incision for creation of a cervical anastomosis. The patient is placed in
the supine position on a friction pad and foot-board with bilateral arms tucked
(Fig.19). Both the neck and abdomen are prepped into the eld. Only a singlelumen endotracheal tube is needed. In anticipation of the operative eld, we prefer
that if a patient requires neoadjuvant treatment that a chemoport be placed in the left
subclavian vein. This keeps the right internal jugular vein free for central venous
catheter placement by the anaesthesiologist and the left neck free for our cervical
dissection. Should a pneumothorax be made when placing the chemoport in the
right subclavian vein, it may cause right sided chest adhesions making an ILE or
3-hole approach more difcult should that technique be used instead of THE.
The THE is this author’s preferred technique with use of the Da Vinci Xi Robotic
platform. Ports are placed as seen in (Fig.20). A exible retractor is placed through
an AirSeal™ port in the right ank to retract segments 2 and 3 of the liver. A
Fenestrated Bipolar is placed in arm 1in the right midclavicular line, and arm 2
holds a 30 degree camera above the umbilicus. In arm 3 we place a laparoscopic
12mm trocar and “piggyback” our robotic advanced energy dissector—the 12mm
trocar is utilized by the bedside assist to staple the left gastric vessels. We prefer this
from the bedside assist rather than the SureForm™ stapling system due to efciency.
It is important to appreciate that the Harmonic ACE™ has a shorter shaft length than
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Fig. 19 Patient
positioning in Reverse
Trendelenberg with the
arms tuck and patient
secure on a friction pad
and foot-board
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the Vessel Sealer, thus must be placed more cephalad in order to gain proper mediastinal reach. Should more reach be needed such as in a taller patient, the trocar can
be “burped” by the bedside assistant to gain cephalad reach. A Prograsp™ is utilized
in arm 4.
The patient is positioned in 30° reverse Trendelenberg and the robot is docked.
Dissection begins by identication of the right gastroepiploic artery and entering
the lesser sac via the gastrocolic ligament lateral to the vessel. Dissection proceeds
cephalad along the greater curvature of the stomach, dividing the short gastric vessels and the posterior gastric attachments (Fig.21). The left crus is visualized and
the posterior mediastinum is entered laterally and then briey anteriorly. The right
crus is the approached by entering the pars accida with an energy device. The right
crus is identied and the phrenoesophagal ligament is divided. Caution must be
taken in patients with a hiatal hernia as the left gastric vessels can be pulled into the
mediastinum. The left gastric artery is identied and a window is made by caudad
dissection. A lipped vascular-load, linear cutting stapler is placed via the 12mm
trocar by the bedside assist and the vessel is divided at its origin, thus capturing the
celiac, left gastric and hepatic nodal basins (Fig.22).
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5mm
SUL
Camera
8mm 12mm
12mm (if Harmonic)
Midline
MCL
8mm
(if Vessel Sealer)
SUL
MCL
Fig. 20 Port placement for the da Vinci Xi system. Note the difference in the 12mm port placement depending on the energy device used. The 5mm right lateral port is typically an AirSeal
The esophagus is mobilized with en bloc lymphadenectomy. Arm 4 is placed into
the retroesophageal space from the right, which allows great visualization of the
posterior and right mediastinum. This maneuver eliminates the need for a Penrose
drain for retraction. We nd safety in carrying out the retroesophageal mediastinal
dissection rst, followed by lateral and then anterior last (Fig. 23). Once the
™
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Fig. 21 Dissection along
the greater curvature of the
stomach, staying high on
the stomach and avoiding
the gastroepiploic vessel
Fig. 22 Stapling of the
left gastric artery and its
lymphatic pedicle. The
stapler is introduced via
the 12mm trocar by the
bedside assistant
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mediastinum is sufciently mobilized, it is this author’s practice to complete the
procedure via a mini-laparotomy. The robot is undocked and the patient brought
back to the at supine position.
A mini upper midline laparotomy is made, and a second surgical team enters and
begins the left neck dissection.
Left neck: An 8cm incision is made along the medial aspect of the left sternocleidomastoid muscle. The vessels are retracted lateral and the thyroid medially.
Blunt dissection is used to circumferentially dissect out the proximal esophagus
using the nasogastric tube as a guide. The recurrent laryngeal nerve is identied and
protected. It is important to dissect posterior and inferiorly rst, meeting the previous mediastinal dissection eld and helping to avoid neurovascular injury in the
neck. The nasogastric tube is retracted into the mouth and the esophagus divided
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Fig. 23 Dissection in the
posterior mediastinum
behind the esophagus.
Note the scaring and
edema present from
neoadjuvant radiation
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with a linear, non-cutting stapler and a scalpel. The nasogastric tube tip is brought
back into the eld tagged with a silk suture to make for easy retrieval later. A new
sterile nasogastric tube is sutured to the proximal esophageal specimen margin.
Mini-laparotomy: The gastric antrum is identied and followed distally towards
the pylorus. A full Kocher maneuver is done. The pylorus is identied just proximal
to the vein of Mayo. A pyloroplasty is then carried out rst by placement of two 2-0
silk stay sutures. A 4cm longitudinal enterogastrotomy is made on the pylorus. The
pylorus is the closed in a Heineke-Mikulicz fashion with interrupted 2-0 silk suture.
The remainder of the gastrocolic omentum is divided as well as any remaining posterior gastric attachments. The esophageal specimen, already divided in the neck is
then brought into the abdomen. The left gastric vein is isolated and divided with a
vascular load linear cutting stapler. The proximal stomach is resected to include the
GE junction and our en-bloc lymphadenectomy (Fig.24). The specimen is passed
off the eld (Fig.25). The gastric conduit staple line is oversewn with silk suture in
a Cushing fashion. We do not tubularize the stomach as we like to preserve as much
stomach as possible to reach into the neck as well as to not disrupt the ow of the
right gastric artery through the wall of the stomach.
The nasogastric tube tip, now located in the abdomen is secured to the top of the
gastric conduit and passed through the mediastinum, maintaining orientation. A
jejunostomy tube is made in a Witzel fashion. The anastomosis is constructed in a
manner similar to Orringer [21]. 3-0 silk stay sutures are placed between the esophagus a stomach. A small gastrotomy is made. A linear cutting 60mm stapler is oriented with the large anvil in the esophagostomy and pointing in the direction of the
patient’s right ear. The remaining opening is closed with interrupted 5-0 Vicryl
suture (Fig.26). The nasogastric tube is passed to just above the pyloroplasty. A at,
closed suction drain is placed adjacent to the anastomosis and the tissue closed
loosely in layers. A chest tube is placed only if the pleural space is inadvertently
entered or resected due to tumor involvement.
ab
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ab c
Fig. 24 Shows the mini-laparotomy was various steps of the operation. (a) Shows the pyloro-
plasty constructed with 2-0 silk suture, (b) showed the transection of the specimen at the gastric
margin, (c) shows the completed formation of the gastric conduit before it’s delivered into the
mediastinum
Fig. 25 (a) Shows the intact esophagectomy specimen. (b) Shows the specimen open, note the
white arrow showing the location of residual tumor and the mucosal changes associated with neoadjuvant chemoradiation
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