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Ростовский Государственный Медицинский Университет

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Книга_1050_Библиотеки_им_академика_М_И_Перельмана

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■ Atransthoracicechocardiogramisobtainedtoassesstheleftventricularejection fractionleftventricularwallmotion.Atreadmillstresstestshouldbeobtained whentheechocardiogramfindingsareabnormal.

■ Priortosurgicalresection,apatient’snutritionalstatusshouldbeoptimized.A preoperativefeedingaccessforenteralnutritionmaybenecessaryincasesof severemalnutrition.Aprealbuminlevelcanbemeasuredtofurtherassessthe patient’snutritionalstatus.

■ Perioperativeantibioticsshouldbegivenwithin30minutesofthefirstincision. Compressionbootsareplacedonthelowerextremitiesandsubcutaneous unfractionatedheparinisgiventominimizetheriskofpostoperativedeep venousthrombosis(DVT).

■ Anarteriallineandcentralvenouscathetershouldbeplacedforintraoperative hemodynamicmonitoring.

■ Anepiduralcathetershouldbeplacedforpostoperativepainmanagement. Epiduralinfusionoflocalanestheticminimizespostthoracotomypainand allowspatientstoparticipateinpulmonarytoiletexercises.

Positioning

■ TheIvorLewisesophagectomytechniqueusestwoincisions.Patientsare positionedinthesupinepositionfirstforthemidlinelaparotomyincision (FIG4).Thesecondportionoftheoperationisperformedthrougharight posteriorlateralthoracotomy(FIG5).Patientsarepositionedintheleft lateraldecubitusposition.Abeanbagisusedtohelpholdpatientsinto position.Theoperatingroombedisflexedtoopentheribspaces.

TECHNIQUES

MOBILIZATIONOFTHEGASTRICCONDUIT

■ Thepatientispositionedsupineontheoperatingtable.Adoublelumen endotrachealtubeisplacedforsinglelungisolation.Anarterialline,central

venouscatheter,andepiduralcatheterareplacedbytheanesthesiateam. CompressionbootsandsubcutaneousheparinaregivenforDVTprophylaxis.

■ Amidlinelaparotomyincisionisperformedfromthexiphoiddowntothe umbilicus.Afullinspectionoftheabdominalcavityisperformedtoruleout tumordisseminationonperitonealsurfacesorlivermetastasis.ABookwalter retractorisusedtoprovideexposure.Thetriangularligamentoftheleftlobe oftheliverisdividedandtheleftlateralsegmentisretractedcephaladto exposetheesophagealhiatus.

■ Thedissectionofthegastricconduitbeginsbyenteringthelessersacalongthe greatcurvatureofthestomach.Therightgastroepiploicarteryshouldbe identifiedandpreserved.Thegreateromentumisdividedalongthegreater curvatureofthestomachwithanultrasonicdissectorbydividedbranchesof therightgastroepiploicarcadeandcarefullypreservingthegastroepiploic trunk(FIG6).

■ Thegastrocolicomentumisdividedtowardtheduodenum.Thestomachis retractedupwardandanyadhesionsbetweenthestomachandpancreasshould becarefullydivided(FIG7).Theduodenumisthenmobilizedwiththe

Kochermaneuver.

■ Theshortgastricvesselsareligatedusingtheultrasonicdissector.Theshort gastricvesselsshouldbeligatedclosetothespleentoavoidthermalinjuryto thestomach.

■ Thelesseromentumisthendividedtowardtheesophagealhiatus.Areplacedleft hepaticarteryshouldbeidentifiedandpreservedifpresent.Therightgastric arterycanbepreservedinmostcaseswhentheanastomosisisperformedin therightthorax.

■ Theleftgastricpedicleisidentifiedalongthelessercurvatureofthestomach. Theleftgastricpedicleisdividedattheoriginfromtheceliacaxisusingan EndoGIAlinearstapler.Thesurroundingadiposetissueandlymphnodes shouldbesweptupwardpriortoligationoftheleftgastricpedicle(FIG8).

■ Thecruraofthediaphragmareidentifiedandthedistalesophagusshouldbe visualized.Thephrenoesophagealmembraneisthendividedtofacilitate mobilizationoftheesophagusaroundtheesophagealhiatus(FIG9).The rightcrusofthediaphragmaredividedifnecessarytopermitfourfingersto fitintotheopenedesophagealhiatus.Thispreventscompressionofthe esophagealconduitandpossibleischemia.

FORMATIONOFTHEGASTRICCONDUIT

■ TheEndoGIAlinearstaplerisusedtodividethestomachalongthelesser curvature.Thestaplelineisstartedalongthelessercurvaturejustproximalto therightgastricartery(FIG10).Thestaplelineshouldendbetweenthe cardiaandthefundus.Thestaplelineisoversewnwithmultipleinterrupted30silksuturestocoverthestaplelinewithserosa.Thegastrictubeshouldbe5 to6cminwidth.

■ Thegastrictubeissecuredtotheremnantofthegastriccardiawithtwo interrupted0-silksutures.Thiswillallowthegastricconduittobepulledinto thechestalongwiththeesophagogastricspecimen.

HEINEKE-MIKULICZPYLOROPLASTY

■ Thepylorusmuscleisidentifiedwithdirectpalpationattheborderoftheantrum ofthestomachandthefirstportionoftheduodenum.Thepylorusmuscleis incisedlongitudinallyusingthecauteryandultrasonicdissector.Theincision iscarriedthroughthemucosallayer.Theincisionisthenclosedtransversely withinterrupted4-0Vicrylsuturesandsecondlayerof3-0silksutures.

JEJUNOSTOMYFEEDINGTUBE

■ TheligamentofTreitzisidentifiedattherootofcolonmesentery.The jejunostomytubeisplacedintheproximaljejunumabout30to40cmfrom theligamentofTreitz.Apurse-stringsutureisplacedontheserosaofthe jejunumusinga4-0chromicsuture.Asmallenterotomyiscreatedwithinthe pursestring.A10-Frjejunostomytubeisplacedthroughtheabdominalwall

andintothejejunum.Thepurse-stringsutureistiedandthejejunostomysite iscoveredwithmultiple3-0silksuturestoimbricatetheserosa.

■ Thejejunostomyinsertionsiteisthensecuredtotheabdominalwallwithfour interrupted2-0silksutures.Thejejunostomytubesiteontheabdominalwall shouldnotbetwistedtoavoidpostoperativebowelobstructionorischemia.

THORACICMOBILIZATIONOFTHE ESOPHAGUS

■ Arightposteriorlateralthoracotomyisperformedandtherightchestisentered throughthe5thintercostalspace.Theserratusanteriormuscleispreserved.

■ Therightlungisisolatedwithadoublelumenchesttubeandtherightlungis retractedanteriorly.

■ Theinferiorpulmonaryligamentisincisedwithcauteryandthelevel9lymph nodesareharvested.Themediastinalpleuraalongtheanterioresophagusis incisedwiththecautery.Thedistalesophagusisdissectedfromthe pericardiumandtheaortaposteriorly(FIG11).Theesophagusisthen encircledwitha1-inPenrosedrain.

■ Theesophagusismobilizedfromtheesophagealhiatustotheazygousvein(FIG

12).TheultrasonicdissectororLigaSuredevicecanbeusedtodividesmall

vesselsandlymphatics.Thethoracicductshouldbesutureligatedifthe

structureisinjuredduringtheesophagealdissection.Thethoracicductenters therightthoraxthroughtheaortichiatusandisusuallylocatedbetweenthe azygousveinandtheaorta.Thethoracicductcrossesovertotheleftsideat T4-T5andpassesbehindtheaorticarch.Thethoracicductpassesposteriorly totheleftcarotidsheathanddrainsintothejunctionoftheleftjugularand subclavianvein.

■ TheazygousveinisroutinelydissectedanddividedwithanEndoGIAlinear stapler.Theesophagogastricanastomosisisusuallyperformedatthelevelof theazygousvein.Incaseswheretheesophagealtumorislocatedin midesopahgus,theesophagealdissectionmayhavetobecarriedmore proximallytowardthethoracicinlet.

ESOPHAGOGASTRICANASTOMOSIS

■ Thegastricconduitispulledintotherightchestandthesuturesattachingtothe esophagogastrectomyspecimenaredivided(FIG13).Theesophagusis divided2cmabovetheazygousveinwithanEndoGIAlinearstapler(FIG

14).Theproximalesophagealmarginanddistalgastricmarginareevaluated

withfrozensection.

■ The2-0Prolenepurse-stringsutureisplacedthroughthemucosaandmuscular layersoftheesophagus.A25-mmor28-mmanvilisplacedintheesophageal lumenandthepurse-stringsutureistiedaroundtheshaftoftheanvil.A secondpurse-stringsutureisplacedaswell.

■ Agastrotomyisperformedalongtheproximallessercurvatureofthegastric conduit.Anend-to-endanastomosis(EEA)circularstaplerisinsertedthrough thegastrotomyandthepinisdeployedproximallyalongthegreatcurvature. TheanvilandEEAstaplerareconnectedandthestaplerisdeployed(FIGS

15and16).

■ Theesophagogastricanastomosisshouldbeinspectedandcheckedfor completeness(FIG17).The“doughnuts”shouldbecompletetoensure esophagealandgastricmucosalapposition.Anasogastrictubeisthenpassed underdirectvision.

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