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258
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M. Jureller et al.
a
Fig. 26 Demonstrates the technique of cervical esophagogastric anastomosis. (a) Shows silk stay
sutures in place with the esophagus and stomach aligned for anastomosis. (b) Shows the GIA stapler in positioned pointed towards the patient’s right ear. (c) Shows completion of the posterior
stapled anastomosis, the anterior wall is then closed with interrupted 5-0 vicryl suture
Postoperatively, nasogastric feeds are initiated and the patient is kept NPO
through post-operative day 5 when an esophagram is performed. After which, the
nasogastric tube is removed and the patient advanced to a mechanical soft diet after
evaluation with the speech therapy team.
Our high volume group has shown repeated good success with this technique
with a leak rate of less than 10% over an 8year period in 130 patients [22], all of
whom were managed conservatively with success. No postoperative mortalities
were contributed to leak. Furthermore, leaks were associated with patients with
chronic obstructive pulmonary disease, and previous gastric surgery such as previous fundoplication or metabolic surgery.
15 McKeown (Three-Hole) Esophagectomy
Three incisions are required for the McKeown technique: a right thoracotomy, an
upper midline laparotomy, and a left neck incision. The right chest is entered rst to
carry out mobilization of the intrathoracic esophagus and mediastinal lymphadenectomy. Once the esophagus has been mobilized, the chest is closed without dividing the esophagus. The patient is then placed in the supine position and the remainder
of the procedure is carried out in similar fashion to the THE.However, blunt mediastinal dissection is not required, as the intrathoracic esophagus has already been
completely mobilized.
The McKeown esophagectomy has both the advantages and disadvantages of the
ILE and THE.An additional incision increases the chance of wound complications
and increased postoperative pain. A unique advantage to this technique is that
pathology at any level can be addressed. Our group prefers this approach with
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259
mid- esophageal squamous cell cancers. We nd that these lesions typically require
more direct dissection, especially since many squamous cell lesions come to surgery late after failures of denitive chemoradiation strategies.
16 Sweet or Left Thoracoabdominal Esophagectomy
The Sweet technique utilizes a left thoracoabdominal incision and neck incision for
creation of a cervical anastomosis, as the aortic arch prevents creation of a high
intrathoracic anastomosis. This technique is rarely employed today, and is included
in the chapter for historical interest. The patient is positioned in a modied right
lateral decubitus position with the abdomen and hips tilted slightly posteriorly. Left
lung is isolation is required. The incision extends from just below the scapular tip,
along the 6th or 7th intercostal space, across the costal margin, and then obliquely
onto the upper abdomen in a paramedian fashion. The abdominal portion of the incision is made rst and once resectability is conrmed, the thoracotomy is made and
the incisions are connected by sharply dividing the costal margin. The diaphragm is
incised circumferentially for 8–10cm, leaving a 2cm cuff for closure. This excellent exposure allows for completion of both the abdominal and chest stages through
a single incision. After resection, the conduit is passed beneath the aortic arch and
the cervical stage with a cervical anastomosis is completed. The diaphragm is closed
and the costal margin is reapproximated with gure-of-eight sutures. The thoracoabdominal incision is then closed in layers after drains are placed.
The Sweet esophagectomy is ideal for locally advanced distal esophageal tumors,
such as tumors invading the diaphragmatic hiatus, as this wide exposure provides
optimal access to the hiatus and gastroesophageal junction (Fig.27). The main disadvantages of this technique include increased postoperative pain owing to the large
incision, as well as risk of costal arch dehiscence and diaphragm dysfunction.
Fig. 27 A left
thoracoabdominal incision
provides excellent
exposure to the distal
esophagus and hiatus
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M. Jureller et al.
17 Colon Interposition Esophagectomy
Many clinical scenarios exist which may render the stomach an unsuitable or
unavailable conduit to restore continuity after esophagectomy. Such scenarios
include previous esophagectomy resulting in leak or conduit necrosis which necessitated conduit resection or returning the conduit to the abdomen. Others include
caustic ingestion with injury to the esophagus and stomach, previous gastrectomy,
history of redo fundoplication, or more commonly the patient status post metabolic
surgery [23]. Particular challenges come with the patient after sleeve gastrectomy,
as the typically used lumen of the greater curvature of the stomach has been resected,
and the main conduit blood supply of the gastroepiploic arcade has been disrupted.
When the traditional gastric conduit is not available, alternatives include colon,
small bowel and myocutaneous grafts. The colon conduit being the most preferred
and frequently used in this case [24]. Many considerations must be taken during a
patients’ workup for candidacy. All undergoing colon interposition esophagectomy
must have a colonoscopy, and mesenteric vessel mapping during workup by CT
angiography and/or conventional angiography (Fig.28). Our group routinely obtains
both imaging methods, as we nd that conventional angiography gives great
dynamic detail regarding the left colon and the presence of the Arc of Riolon, marginal artery of Drummond, or if a meandering artery/artery of Moskowitz is present.
Contraindication to the use of colon as a conduit include previous diverticulitis,
family colon cancer pathologies and personal history of inammatory bowel disease, among others. Whether the right or left colon is used for replacement is of
some debate. There are some relative guides as seen in Table1, but much is also left
to determination and comfort of the surgical team. The patients undergo a mechanical and antibiotic bowel prep the evening before surgery.
The operative approach is done via laparotomy and left neck incision as a transhiatal approach. When the right colon is used, its vascular supply is based off the
middle and left colic arteries [25]. First, a complete right medialization of the colon
abc
Fig. 28 Conventional angiography demonstrating visceral ow patterns. (a) Shows the SMA, (b)
shows the middle colic artery, and (c) the IMA with the Marginal artery of Drummond
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261
Table 1 Considerations in
choice of right or left
colon conduit
Fig. 29 Indocyanine green
uorescence of the right
colon ready for
transposition into the
mediastinum
Right colon Left colon
Based off middle colic Based off IMA, may be problematic
in atherosclerosis
Wider conduit Slimmer conduit
Vascular supply variable If history of pancreatitis, IMV may
be compromised
Antiperistalsis Isoperistalsis
along the white line of Toldt is performed. Bulldog vascular clamps are placed at the
origin of the ileocolic artery and other branches of the right colic artery at their
future transection sites and non-crushing bowel clamps are placed at the ileocecal
junction and along the transverse colon between the right and left branches of the
middle colic artery. Adequate blood supply is conrmed with subjective color
change of the bowel, intact doppler ow within the terminal branches of the right
colon mesentery, and indocyanine green uorescence imaging (Fig.29). After conrmation of adequate blood supply, the bowel and vascular pedicles are divided at
the above-mentioned locations. An appendectomy is performed. A mediastinal
mobilization is then performed either in the posterior mediastinum with esophagectomy should the organ be in-situ or an anterior mediastinal tunnel if an esophagectomy was already been performed and the posterior mediastinum scarred down. If
the anterior mediastinum used, some authors will resect the medial aspect of the left
clavicle to prevent luminal impingement and venous outow obstruction [26]. The
right colon is brought through the mediastinum in an antiperistaltic fashion. The
proximal esophagus is anastomosed to the cecum with the linear staple technique as
described in our above transhiatal approach. The proximal transverse colon of the
conduit is anastomosed to the proximal gastrointestinal tract and an ileocolic anastomosed done, thus restoring gastrointestinal continuity. A jejunostomy tube
is placed.
If the left colon is used, the blood supply is based off the inferior mesenteric
artery via the marginal artery of Drummond. The left colon and splenic exure are
completely medialized, with preservation of the ureter. The blood supply is assessed
in a similar manor of non-crushing clamping, doppler and indocyanine green uorescence assessment as described above. Here the distal sigmoid colon and transverse colon between the middle and left branches of the middle colic artery are
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M. Jureller et al.
clamped as is the middle colic artery and then divided assuming adequate perfusion.
As described above the mediastinum is dissected. The left colon is brought through
the mediastinum in an isoperistaltic orientation. Anastomoses are performed similarly as described above.
A Jackson Pratt drain is placed in the left neck and nasoenteric tube positioned
in the conduit. Post operatively, the patient is admitted to the surgical intensive care
unit. Jejunostomy feeds are initiated on postoperative day 2. A video esophagram is
obtained on day 5 to evaluate for leak—if negative, the nasoenteric tube is removed
and the patient is advanced to a mechanical soft diet with the assistance of the
speech therapy team.
18 Conclusions
Esophagectomy is a complex, multistep, multidisciplinary procedure with multiple
resection techniques. The approach to each patient must be individualistic depending on the patients’ pathology the surgeons’ expertise.
References
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7. Schuchert MJ, Luketich JD, Landreneau RJ.Management of esophageal cancer. Curr Probl
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2013;96:1919–26. https://doi.org/10.1016/j.athoracsur.2013.07.119.
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patients with mucosal adenocarcinoma of the esophagus. Gastroenterology. 2014;146:652–660.
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11. Jung HK, Tae CH, Lee HA, et al. Treatment pattern and overall survival in esophageal cancer during a 13-year period: a nationwide cohort study of 6,354 Korean patients. PLoS One.
2020;15:1–14. https://doi.org/10.1371/journal.pone.0231456.
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13. Swisher SG, Wynn P, Putnam JB, et al. Salvage esophagectomy for recurrent tumors after
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15. Ishihara R, Mizusawa J, Kushima R, et al. Assessment of the diagnostic performance of
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16. Krill T, Baliss M, Roark R, et al. Accuracy of endoscopic ultrasound in esophageal cancer
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esophageal or junctional cancer. N Engl J Med. 2012;366(22):2074–84.
18. Campos GM, Jablons D, Brown LM, etal. A safe and reproducible anastomotic technique
for minimally invasive Ivor Lewis oesophagectomy: the circular-stapled anastomosis with
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ejcts.2010.01.010.
19. Boshier PR, Anderson O, Hanna GB.Transthoracic versus transhiatal esophagectomy for the
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20. Hulscher JBF, Tijssen JGP, Obertop H, et al. Transthoracic versus transhiatal resection for
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22. Logarajah S, Cudworth S, Doty M, etal. Factors associated with anastomotic leak after transhiatal esophagectomy: a single-institution analysis. J Gastrointest Surg. 2023;27(2):398–401.
23. Jureller M, Logarajah SI, Van Meter TA, etal. The novel conduit: challenges of esophagectomy after bariatric surgery. J Gastrointest Surg. 2022;27:653–7. https://doi.org/10.1007/
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24. Hung PC, Chen HY, Tu YK, Kao YS.A comparison of different types of esophageal reconstructions: a systematic review and network meta-analysis. J Clin Med. 2022;11:5025. https://
doi.org/10.3390/jcm11175025.
25. Fürst H, Hartl WH, Löhe F, Schildberg FW.Colon interposition for esophageal replacement an
alternative technique based on the use of the right colon. Ann Surg. 2000;231:173–8.
26. Boukerrouche A. Isoperistaltic left colic graft interposition via a retrosternal approach for
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Laparoscopic Splenectomy
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NicoleLunardi andHillaryB.Prince
1 Indications
There are several pathologies that may require splenectomy, ranging from autoimmune disorders, benign or malignant hematologic disorders, vascular disorders,
benign or malignant splenic masses and traumatic splenic rupture (Table 1) [1].
Immune idiopathic thrombocytopenia remains the most common elective indication
for splenectomy. First-line treatment in these patients is glucocorticoids, but only
40% will have a response to treatment and only 50% of those responders will have
Table 1 Indications for splenectomy
benign hematologic Malignant hematologic Vascular disorders
Immune idiopathic
thrombocytopenia
Thrombotic
thrombocytopenia
purpura
Hereditary
spherocytosis
Thalassemia
Sickle cell disease
Autoimmune
hemolytic anemia
Lymphoma (Hodgkin
and non-Hodgkin)
Hairy cell leukemia
Myeloproliferative
disorders
Lymphoproliferative
disorders
Malignant vascular
tumors
Lymphangiosarcoma Cysts Traumatic
Aneurysms Primary
Splenic
masses
Abscesses Iatrogenic
splenic
tumor
Splenic
rupture
injury
N. Lunardi · H. B. Prince (*)
Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
e-mail: nicole.lunardi@utsouthwestern.edu; hillary.prince@utsouthwestern.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_21
265© The Author(s), under exclusive license to Springer Nature
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a sustained response [2]. With the development of immunologic therapy, the role of
splenectomy for ITP may become more limited [3]. Patients with hereditary spherocytosis often undergo a splenectomy in childhood to decrease transfusion requirements, skeletal abnormalities and formation of bilirubin gallstones [4]. While many
of the other benign and malignant hematologic diseases are treated medically, surgery may be indicated in the setting of refractory pancytopenia, constitutional
symptoms, abdominal pain, and/or early satiety [1]. Absolute contraindications to
the laparoscopic approach include hemodynamic instability, inability to tolerate
insufation, uncontrolled coagulopathy, severe cardiopulmonary disease, cirrhosis
with portal hypertension, and pregnancy. Relative contraindications may include
massive splenomegaly, prohibiting placing the specimen in an extraction bag, and
multiple prior abdominal surgeries. It is important to note that, while the role is
limited, there may be a subset of traumatic splenic injuries that are appropriate for
management with laparoscopic splenectomy. This may be considered if the patient
remains hemodynamically responsive to transfusion but nevertheless requires ongoing transfusions, with no concern for other intrabdominal injuries, likely in a facility
without interventional radiology availability [5].
N. Lunardi and H. B. Prince
2 Preoperative Preparation
There are several important considerations in the preoperative history, physical and
evaluation for an elective laparoscopic splenectomy. Patients should be asked about
symptoms specic to a personal or family history of splenomegaly (abdominal pain,
early satiety), benign/malignant hematologic disease (constitutional symptoms,
fatigue, coagulopathy), cirrhosis or liver failure, recent trauma, and/or infectious
processes. Patients should be asked if they are on glucocorticoids (dose and length
of treatment) to assess the need for intra- and post-operative stress-dose steroids. On
physical exam, stigmata of portal hypertension, liver failure and splenomegaly
should be assessed. If not done already, a hematologist should be involved in the
evaluation for hematologic, immune and myeloproliferative disorders, which may
include peripheral blood smears and bone marrow analysis. Their input is essential
in anticipating the pre-operative and intra-operative transfusion requirements. They
may also suggest pre-operative intravenous immunoglobulin for thrombocytopenic
patients.
A valid type and screen will be essential for the operation should the need for
transfusion arise. Pre-operative imaging with a CT abdomen/pelvis with intravenous contrast will help identify the size and anatomy of the spleen, accessory
spleens, splenic vasculature and the surrounding structures. Other imaging modalities have limited role in preoperative planning, including ultrasound for portal
hypertension and MRI for solid peri- or intra-splenic tumors. Preoperative splenic
artery embolization could be considered in the case of massive splenomegaly or
portal hypertension. This will decrease intraoperative blood loss and decrease the
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technical difculty of splenic mobilization [6]. Patients undergoing a splenectomy
will need vaccinations for encapsulated organisms (Hemophilus inuenza B,
Streptococcus pneumoniae, Neisseria meningitides) to prevent a post-operative
overwhelming post-splenectomy infection (OPSI) [7].
267
3 Positioning andAnesthesia
It is vital to anticipate and communicate transfusion and stress dose steroid requirements with your anesthesia colleagues. Antibiotic and deep venous thrombosis prophylaxis should be given 1h prior to skin incision. When the patient is placed on the
operating room table, sequential compression devices should be applied and all
pressure points should be padded. After general anesthesia is administered and the
airway is secured, a nasogastric or orogastric tube should be placed to decompress
the stomach to improve intraoperative visualization. A foley catheter may be placed
based on surgeon and anesthesia discretion.
The patient can be positioned in the supine, right lateral decubitus, or anterolateral positions. Each position has its benets and drawbacks. You may consider the
supine position, if the patient has massive splenomegaly to improve visualization of
the hilum or if you are doing other intrabdominal procedures. However, in the right
lateral decubitus or the anterolateral positions, you can use a beanbag or ex the
table to increase the space between the costal margin and iliac crest. By doing so,
you maximize visualization and ease the difculty of dissection for most cases. It is
important to note, conversion to an open procedure is easiest from the supine position and most difcult from the right lateral decubitus position. In all patient positions, be careful to maintain the spine, extremities, and shoulders in a neutral
position.
4 Description ofProcedure
4.1 Abdominal Access
There is no singular superior technique of gaining intrabdominal access for a laparoscopic splenectomy (OptiView, Veress Needle, Hasson Technique, etc). It is our
practice to use a Veress needle at Palmer’s point in the left upper quadrant.
Intrabdominal position is conrmed with a saline drop, aspiration of non-gastric/
bilious uid, and a starting insufation pressure of around 8mmHg. At that point,
insufation is initiated until a pressure of 15mmHg is obtained.
A 5mm port in placed in the left upper quadrant just inferior to the costal margin
in the anterior axillary line. A laparoscope in inserted and the abdominal cavity is
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inspected for injury from the Veress and trocar placement. Once it is veried no
injury has occurred, the Veress needle is removed under direct visualization. The
remaining ports are placed under direct visualization: 10mm supraumbilical camera port, 5mm sub xyphoid, and 12mm left lower at the midaxillary line (PICTURE).
N. Lunardi and H. B. Prince
4.2 Mobilization ofSplenic Ligaments
Dissection begins with the splenocolic ligament. The splenic exure of the colon
should be retracted inferiorly. Using traction and countertraction, the splenocolic
ligament is identied and divided using sharp dissection and electrocautery. If there
are omental attachments, there may be accessory vessels which should be divided
using a bipolar electrocautery. This dissection is continued laterally moving cephalad towards the splenophrenic ligament. By doing so, the posterior hilum is being
exposed. The splenophrenic ligament should not be divided at this point as it can
help with maintaining visualization of the hilum.
4.3 Devascularization oftheSpleen
At this point, attention should be turned medially. To enter the lesser sac, the greater
curvature is grasped at the level of the inferior pole of the spleen and retracted anteriorly and to the patient’s right. The short gastric vessels should be divided using
bipolar electrocautery in a stepwise fashion moving cephalad until the left crus of
the diaphragm is visualized. The anterior surface of the pancreas, splenic hilum with
the splenic artery and vein should be visualized. The splenic artery runs inferior and
anterior to the vein. Once the vascular pedicle is circumferentially dissected using
blunt dissection and electrocautery, an endovascular vascular stapler is used to
divide the artery and vein en masse. Prior dogma suggested diving the artery and
vein together would lead to an arteriovenous stula; however, it is acceptable, and
therefore our practice, to take the structures together using a vascular stapler. It is
important to note additional vascular staplers maybe required to divide splenic vein
branches along the medial margin of the spleen. At this point, spleen should be
completely devascularized.
4.4 Inspecting forInjury andRemoving theSpecimen
The tail of pancreas should be carefully inspected for possible pancreatic injury.
Any concern for injury should prompt placement of a 15Fr blake drain to monitor
and control any possible pancreatic stula. The splenophrenic ligament should now
be divided, unless the attachment would assist in placing the specimen in an extraction bag. The extraction bag is placed in the abdomen via the 12mm port. Once the
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