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Ростовский Государственный Медицинский Университет

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Книга_1050_Библиотеки_им_академика_М_И_Перельмана

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theperitonealreflectionoverlyingtheangleofHis.

■ Theesophagusisdissectedofftheleftcrusofthediaphragmandesophagus encircledwitha1-inPenrosedrain(FIG5).

■ TheesophagusandGEjunctionarethendissectedfreeofthecruralconfluence oftheesophagealhiatus,andesophaguswithassociatedperiesophagealfatty tissueandlymphnodesdissectedfreeoftheesophagealhiatusandunderlying aorta.

■ IftheesophagusandGEjunctionarefreeofsurroundingstructures,resection canproceed.Ifadherenttoorinvadingthepleura,pericardium,ordiaphragm (T4a),resectionofthesestructurescanbeperformed.Ifadherenttotheaorta, vertebralbody,ortrachea(T4b),resectionshouldbeaborted.

MobilizationoftheStomachandDuodenum

■ Onceitisdeterminedthatresectioncanproceed,thestomachandduodenumare mobilized.Mostoften,thestomachisusedastheconduitforreconstruction followingTHE.Therefore,mobilizationofthestomachforpurposesof proceedingwiththeesophagectomyandforpurposesofthecreationofthe gastricconduitoccursimultaneously.

■

Therightgastroepiploicarteryandveinareidentifiedalongthegreatercurvature ofthestomach.Anadequatepulseinthisvesselisimperativeifthestomach istobeusedforthereconstruction(FIG6).Thesevesselsterminateatthe barearearoughlyone-halfthedistancealongthegreatercurvaturebetween thepylorusandGEjunction.Itisimperativetopreservethesevesselsasthey arethebloodsupplytoandfromtheconduit.

■ Oncethesevesselsareidentified,thegastrocolicligamentisenteredseveral centimetersfromthebareareaenteringthelessersac.

■ Usinganelectrosurgerydevice,thegastrosplenicligamentandshortgastric vesselsaredividedproceedingalongthegreatercurvaturetowardthe esophagealhiatus.Placingasurgicalcliponthedistalendsoflargervessels, includingtheleftgastroepiploicartery,canensureongoinghemostasisof thesevessels.Theposteriorleafletofthegastrosplenicligamentislikewise dividedasarethecongenitaladhesionsofthestomachtotheanteriorsurface ofthepancreas.Thisfreesthegreatercurvature.

■ Divisionofthegastrocolicligamentthenproceedsdistally,payingcareful attentiontostayatleastafewcentimetersawayfromtherightgastroepiploic vessels(FIG7).Carefulattentionshouldbepaidtonotplacingtractionor traumatothesevesselswhilefreeingthestomachfromthecolon.Thisis especiallytrueasonefreesthestomachfromtheanteriorsurfaceofthe

pancreasandapproachestheoriginofthesevesselsfromundertheduodenal bulb.Tractionofthevein,inparticular,cantraumatizethesevesselsresulting inimpairedvenousoutflowandconduitvenouscongestion.

■ Afterfreeingthestomachfromthecolon,aKochermaneuverisperformedto permitmobilizationoftheduodenum.AnadequateKochermaneuverpermits mobilizationofthepylorustoreachtheesophagealhiatus(FIG8).

■

Atthispoint,theremainderofthegastrohepaticligamentisdividedandleft gastricpedicleisidentified.

■ Thelymphnodesalongtheleftgastricpedicleandceliacaxisandsurrounding aortaaredissectedfreeoftheoriginoftheleftgastricarteryandincludedin thesurgicalspecimen.Theleftgastricarteryandveinarethendividedwith eitheravascularloadofasurgicalstaplerorsutureligated.

■ Thestomachisnowfreeofitsupperattachmentsandvasculature.Ifacolon conduitispreferred,preparationofthecolonshouldproceed.Ifagastric conduitispreferred,thegastricconduitiscreatedtoavoidtraumatothe conduitduringretractionofthestomachnecessaryfortheinferiormediastinal dissection.Thisalsoallowsverificationoftheadequacyofthebloodsupply totheapexoftheconduitandlengthoftheconduitpriortoproceedingwith thetranshiataldissection.Thiswillbediscussedinthefollowingtext.Forthis discussion,themediastinaldissectionwillbedescribed.

■ WithaPenrosedrainaroundtheGEjunctionforcaudalretractionofthestomach andloweresophaguswithassociatedlymphatictissueisdissectedunder directvisualizationfromthelowermediastinum.Thisdissectionisfacilitated byamediumhandheldmalleableretractorandtheuseofanelectrosurgical device.Approximately5to10cmofmediastinalesophaguscanbedissected underdirectvisualizationbythistechnique.Mobilityofthemediastinal esophagustoassurefeasibilityandsafetyofatranshiatalbluntdissectionis verified.

■ Afterthelimitsofdirectvisualizationarereached,bluntmediastinaldissection canproceed.Toassurepropertactileorientationoftheesophagusduring bluntdissection,a44-Frbougiedilatororequivalentisplacedinthe esophagus.

■ Thehandisthenfirstadvancedposteriortotheesophagus,betweenthe esophagusandaorta.Thesurgeon’sfingersarethenadvancedupthisplane withpressureonthebougiecontainingesophagustoassurepropertissue

planedissection(FIG9).

■ Thesamedissectionisthenperformedanteriortotheesophagus.

■ Ifvagalnervesparingisplanned,thevagusnervesareelevatedoffthe esophagusbyhookingthenerveswiththeindexfingerandbluntlydissecting themdownandofftheesophaguswheretheyarethendissectedfreefromthe GEjunctionandstomach.Asthisoperationismostoftenperformedfor malignancy,divisionofthevagalnervesisrequiredtoassureproper oncologicdissection.Thenervesarethendividedatthelevelofthehiatus withtheelectrosurgerydevice.

■ Thiscompletestheabdominalstomachandesophagusmobilization.

CervicalandUpperMediastinalEsophagealMobilization

■ Thecervicalesophagusisapproachedthrua5-cmincisionanteriortotheleft sternocleidomastoidmuscle.Theskin,subcutaneoustissues,andplatysmaare dividedwithelectrocautery(FIG10).

■ Thethinfasciallayersurroundingtheanteriorborderofthesternocleidomastoid muscleisincisedwithcautery.

■ Thedissectioniscarriedmedialanddeeptothesternocleidomastoidmuscle.The omohyoidmuscleisidentifiedanddividedwithcautery.Theinferiorthyroid arteryandmiddlethyroidvein,ifidentified,areligatedwithfinesilkor absorbablesuture.

■ Dissectioniscarriedmedialtothecarotidsheathwithgentlelateraltractionon thesternocleidomastoidandcarotidsheathandmedialtractiononthetrachea andthyroid.Therecurrentlaryngealnerve(RLN)isidentifiedandpreserved adherenttothetracheoesophagealgroove.Dissectioniscarrieddowntothe prevertebralfasciaallowingthesurgeontothenpasstheindexfingerbetween theprevertebralfasciaandesophagus.

■ Thecervicalesophagusisthensharplydissectedfromtrachea,beingcarefulto notdissectfreenorinjuretheRLN.Oncefreeofthetrachea,abluntrightangleclampplacedbetweenthetracheaandesophagus,rotatedandadvanced

totheprevertebralfasciafacilitatesplacementofaPenrosedrainaroundthe esophagus(FIG11).

■ Upwardtractionisplacedonthecervicalesophagusandbluntmediastinal dissectionoftheupperandmiddlethirdoftheesophaguscanensue(FIG9). Thesurgeonmaintainscontactbetweenthevolaraspectofthefirsttwo fingersandtheesophagusatalltimestothepropertissueplaneofdissection. Again,asmall-caliberbougiedilatorplacedintheesophagusfacilitatestactile feedbackoftheesophagus.

■ Withanteriorandupwardtractionofthecervicalesophagusandcaudal retractiononthestomach,ahandisinsertedthruthehiatusposteriortothe esophagusandismetbyfingersinsertedthrutheneckincisiondownthe prevertebralplane.Looseareolarattachmentsaredivideduntilfingersmeet.

■ Thesamedissectionisthenperformedanteriortotheesophagus.When performingthisdissection,thesurgeonmustmaintainconstantpressureon theesophagustoavoidinjurytothemembranoustrachea.Boththeanterior andposteriorplanescanusuallybedissectedrelativelyeasily.

■ Havingfreedtheesophagusfromitsanteriorandposteriorattachments,the lateralattachmentsarethendivided.Thisisoftendonewithacombinationof

directdownwardpressureontheseattachmentswiththeindexfingerfrom aboveorbyplacingtheinferiorindexfingerabovetheattachmentpulling downalongtheinsertionoftheattachmentintotheesophagus.

■ Alternatively,thebougiecanberemovedfromtheesophagusandthelateral attachmentsdividedunderdirectvisualizationastheesophagusisretracted anteriorlyoutthecervicalincision.Usually,somesortofbimanualdissection intheposteriormediastinumisrequired.

■ Atanypointwherethisdissectionprovesdifficultbecauseofdifficultadhesions; fusedtissueplanesespeciallyinthevicinityofthemembranoustrachea, carina,andazygousvein;lackofmobilityoftheesophagus;orexcessive bleeding,thebluntdissectionshouldbeabandonedanddissectionunder directvisualizationperformedviaanincisionintherightchest.

RemovaloftheEsophagus

■ Aftercompletemobilizationoftheesophagus,thecervicalesophagusis deliveredintothenextforseveralcentimetersanddividedleaving approximately20cmoflengthtotheesophagus.Theremainingesophagus cansubsequentlybedividedfurtheratthetimeofanastomosis.

■ A1-inPenroseisaffixedtothedistalesophagusandthestomachandesophagus drawndownthruthehiatusdraggingthePenrosethrutheesophagealbedinto theabdomen.Thiswillallowthereconstructionconduittobeattachedtothe Penroseanddeliveredcephaladupintothecervicalincisionforsubsequent anastomosistothecervicalesophagus(FIG12).

RECONSTRUCTION:GASTRICCONDUIT

CreationofGastricConduit

■ Aftermobilizationofthestomach,thegastricconduitiscreated.Thisisbest donepriortocompletionofthemediastinaldissectionsoastoprotectthe conduitfromtraumaduetomanipulationofstomachduringdissection.

■ Thegoalsofcreatingthegastricconduitareasfollows:

■

Createagastrictubebasedonthegreatercurvaturebloodsupply.

■

Createagastrictubeofsufficientlengthtoreachintothecervicalincision.

■ Dividetheproximalstomachatapointassuringnegativesurgicalmargin, usually5cmdistaltotheGEjunctionalongthegreatercurvature.

■ Resectthelessercurvatureofthestomachtoincludethelessercurvature

lymphaticdrainagealongthedistributionoftheleftgastricartery.

■ Sixcentimetersfromthepylorusalongthelessercurvature,roughly correspondingtotheincisuraangularis,thelessercurvatureneurovascular pedicleissutureligated.Carefulattentionisdirectedatpreservingthe integrityoftherightgastricartery.

■ Usingasurgicalstaplingdevice,thestomachisdividedfromthispointalongthe lessercurvatureparalleltothegreatercurvaturecreatinga5-cmwidegastric tube(FIG13).Thedivisionofthestomachiscompleted5cmfromtheGE junctionalongthegreatercurvature(FIG14).Forthisstep,a“thick”loadof thestaplingdeviceisrecommended.

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