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Allen MS, Miller DL, Deschamps C,
gical factors influence the outcome
Transhiatal Esophagectomy— Intraoperative Disasters
Mark B. Orringer
4
Introduction
In the mid-1970s, transhiatal esophagectomy
(THE) without thoracotomy and the cervical
esophagogastric anastomosis (CEGA) was rediscovered [1]. Prior to that time, the operation was
seldom used, primarily in patients undergoing a
laryngopharyngectomy for carcinoma and esophageal replacement with stomach [2, 3]. THE circumvented the leading complications associated
with a traditional transthoracic esophageal resection and intrathoracic esophagogastric anastomosis—(1) respiratory insufficiency associated with
a combined thoracoabdominal operation and (2)
mediastinitis from an intrathoracic esophageal
anastomotic leak. Detractors of the operation
argued that the “blind” mediastinal dissection
would inevitably result in uncontrollable hemorrhage, and inability to do as complete a mediastinal lymph node dissection as with the traditional
open approach made it an unacceptable operation
from an oncologic standpoint. With now more
than 30 years of experience with THE, these latter
concerns have not been realized, and numerous
reports in the surgical literature have documented
the relative safety and efficacy of this approach
and with survival comparable to that achieved
with transthoracic esophagectomy for carcinoma
[4–8]. As a result, the author regards THE and
M. B. Orringer ()
Section of Thoracic Surgery, University of Michigan
Medical Center, Ann Arbor, MI, USA
e-mail: morrin@med.umich.edu
CEGA as the approach of choice in patients requiring esophageal resection and reconstruction
for both benign and malignant diseases [9].
As is the case with every major operation,
a successful outcome is strongly influenced by
careful patient selection and a highly organized
and consistent intraoperative approach. Intraoperative “disasters,” primarily hemorrhage and
airway tears, associated with THE are fortunately
rare and are often retrospectively predictable by
assessing the appropriateness of patient selection
for the operation. In our report of 2007 THEs, the
operation was possible in 98 % of those in whom
it was undertaken [9]. However, there were four
(0.19 %) intraoperative deaths from uncontrollable hemorrhage occurring during transhiatal
mobilization of the esophagus from the posterior
mediastinum. Inordinate intraoperative bleeding
(> 4000 ml) occurred in 8 additional patients: 4
intramediastinal due to either a torn azygos vein
(3) or large prevertebral collateral vein (1); 3 in-
traabdominal due to portal hypertension from
cirrhosis (2) or splenic vein injury (1); and 1
from a right ventricular laceration during chest
tube insertion. What was popularized 30 years
ago as a “blunt esophagectomy” has become
much more of a controlled mediastinal dissection
through the hiatus, clamping vascular esophageal
attachments with 13ʺ long right-angle clamps,
and dividing and ligating them through the hiatus. Thus, the average intraoperative blood loss
has fallen from a median of 510 ml in those operated upon between 1976 and 1998 to 300 ml
in those operated upon between 1998 and 2006
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_4,
© Springer Science+Business Media New York 2015
35
36 M. B. Orringer
Table 4.1 Intraoperative blood loss with transhiatal esophagetcomya (2007 patients). (Reproduced with permission
from [14] © Wolters Kluwer 2005)
Group I (1976−1998) Group II (1998–2006)
No. Range (cc) Mean (cc) No. Range (cc) Mean (cc)
Benign 276 100–4000 795 203 50–2000 366
Carcinoma
Total 1054
a
Excludes 4 intraoperative deaths, 3 from Group I and 1 from Group II, 2 with benign disease and 2 with carci-
noma, and 8 surviving patients, 6 in Group I and 2 in Group II, who experienced inordinate intraoperative blood loss
( > 4000 cc.)
778
35–3700 635
35–4000 677 942 15–3100 368 (p ≤ 0.0001)
739
15–3100 368
(p < 0.0001) (Table 4.1). Overall, a thoracotomy
was performed to control mediastinal bleeding during the esophagectomy in nine patients
(< 1 %) and was successful in five.
Both massive intraoperative bleeding and a
tracheal tear complicate < 1 % of all THEs. Neither of these events is commonly mentioned in
review articles on the operation. Because these
are such relatively uncommon occurrences, a
periodic intraoperative “fire drill”—“walking
through” the steps of controlling untoward mediastinal bleeding or an airway tear encountered
during a THE, including indications for a thoracotomy and selection of the appropriate side—
may prove lifesaving if these “disasters” occur.
Indications and Contraindications
toTHE
The surgeon considering a THE must be keenly
aware of clinical “red flags” that may portend
major intraoperative hemorrhage or injury to the
adjacent airway. In the majority of patients requiring an esophageal resection and reconstruction, THE and a CEGA are applicable. In the last
reported series of 2007 THEs by the author and
his associates, there were 1525 (76 %) operations
for carcinoma and 482 (24 %) for benign disease (Table 4.2) [9]. In patients with achalasia,
the common indications for esophageal resection were a failed prior esophagomyotomy, often
with a subsequent reflux stricture, and a tortuous
megaesophagus (> 6 m) [10]. Technical features
unique to achalasia and increasing the likelihood
of bleeding during a THE include (1) adherence
of the myotomized segment to the descending
thoracic aorta; deviation of the megaesophagus
into the right chest; (2) larger than usual aortic
esophageal arteries; and (3) a wider than usual
cervical esophagus, which is more difficult to
mobilize and encircle. While the need for an
esophagectomy for a reflux stricture has been
dramatically reduced by the advent of proton
pump inhibitors (PPIs), the number of failed
laparoscopic antireflux operations is increasing, many after multiple procedures, or with perihiatal mesh, often with erosion into the esophagus. In the author’s experience, the likelihood of
achieving long-term reflux control and/or relief
of dysphagia after two or more prior antireflux
operations is so low that esophageal resection
and reconstruction are the “best” alternative if a
reoperation is advised. However, the decision to
resect the esophagus for benign disease should
not be made lightly. Complaints of occasional
reflux or intermittent dysphagia associated with
a recurrent hiatal hernia, for example, may be
less problematic in the long run than an esophageal anastomotic stricture or chronic dumping
syndrome which may follow an esophagectomy.
With mesh erosion into the esophagus, there is
little option other than an esophageal resection.
The distal periesophageal and esophagogastric
junction inflammatory reaction associated with
a mesh erosion may be extensive and result in
bleeding as the inflammatory mass is mobilized
away from the adjacent aorta. Parenthetically,
although the mesh erosion is at the esophagogastric junction, a THE and CEGA is a better
option than a limited distal esophagectomy and
low intrathoracic esophagogastric anastomosis, particularly in an infected field due to local
sepsis from the erosion. This latter operation insures lifelong gastroesophageal reflux and should
never be done for benign disease. The author has
Table 4.2 Indications for transhiatal esophagectomy (2007 patients). (Reproduced with permission from [14] Wolt-
ers Kluwer 2005)
Number (%)
Patients Group I-1063 pts Group II-944 pts Total-2007
1976–1998 1998–2006 1976–2006
Benign conditions 278 (26
Neuromotor dysfunction 92 (33 %) 47 (23 %) 139 (29 %)
Achalasia 69 44 113
Spasm/dysmotility 21 3 24
Scleroderma 2 0 2
Stricture 74
Gastroesophageal reflux 40 7 47
Caustic ingestion 18 6 24
Radiation 4 2 6
Other 12 6 18
Barrett’s mucosa with high-grade dysplasia 53
Recurrent gastroesophageal reflux 21 (8 %) 6 (3 %) 27 (6 %)
Recurrent hiatus hernia 14 (5 %) 14 (7 %) 28 (6 %)
Acute perforation 15 (5 %) 9 (5 %) 24 (5 %)
Acute caustic injury 5 (2 %) 1 (1 %) 6 (1 %)
Other 4 (1 %) 16 (8 %) 20 (4 %)
Carcinoma of the intrathoracic esophagus
Site 785 (74 %) 740 (78 %) 1525 (76 %)
Upper third 35 (4 %) 16 (2 %) 51 (3 %)
Middle third 164 (21 %) 63 (9 %) 227 (15 %)
Lower third and/or cardia
a
Includes pathologic gastric carcinomas involving the cardia and lower esophagus
a
%) 204 (22 %) 482 (24 %)
%) 21 (10 %) 95 (20 %)
(27
%) 90 (44 %) 143 (30 %)
(19
586 (75 %) 661 (89 %) 1247 (82 %)
374 Transhiatal Esophagectomy—Intraoperative Disasters
recently learned of such a patient who developed
a low esophagogastric anastomotic leak following a limited transabdominal resection for mesh
erosion, survived this, and presented more than 2
years later with an aorto-esophageal fistula at the
site of the prior anastomotic leak—an extremely
rare cause of late major hemorrhage associated
with an intrathoracic esophageal anastomosis.
This was controlled with an endovascular aortic
stent.
While in the current experience of the author
and his associates with more than 3000 THEs,
this operation has been possible in 98 % of those
requiring an esophagectomy, and the safe surgeon
must recognize that there are contraindications
to proceeding with the procedure. Patients with
upper and mid-third esophageal cancers invading
the adjacent airway (proven with bronchoscopy
and biopsy, which should always be performed
as a part of the preoperative evaluation) are not
candidates for a THE. When an esophageal tumor
is located in the mid-esophagus in proximity to
the carina and main bronchi, at approximately
25 cm from the upper incisor teeth at esophagoscopy, a more difficult transhiatal esophageal
mobilization than with a distal carcinoma is usually encountered, and the risk of an airway tear is
increased. Those with histologically documented
stage IV disease (distant metastasis) are similarly
not candidates for resection; this includes the patient found to have “just” a 1-cm liver metastasis
at the time of abdominal exploration. Systemic
disease cannot be cured with local therapy (i.e.,
surgery). Without question, the single most important contraindication to proceeding with a
THE is the surgeon’s assessment of esophageal
mobility on palpation through the hiatus. Fixation of the esophagus or its contained tumor to
adjacent mediastinal structures can result in an
untoward bleeding from a torn aorta or azygos
38 M. B. Orringer
vein or a tracheal tear during an attempted THE.
Surgical judgment is critical in such situations.
Prior radiation therapy does not preclude a THE,
but the technical difficulty of mobilizing the
esophagus may be greatly increased.
Preoperative Risk Factors for Bleeding with a THE
While it may seem obvious, a careful history to
rule out bleeding tendencies or a family history
of clotting disorders should always be obtained.
The patient population requiring an esophagectomy is often older, and a number of conditions
more common in this group result in the need for
anticoagulation and platelet inhibitors, which
may result in untoward bleeding with a THE unless carefully monitored and discontinued for
an appropriate time before surgery. Three of the
most frequent indications for anticoagulation
among these patients are chronic atrial fibrillation, coronary artery stents, and prior thromboembolic disease, particularly that in association
with neoadjuvant chemotherapy and radiation
therapy for esophageal carcinoma [11–13].
A history of prior esophageal surgery, par-
ticularly an esophagomyotomy, which may result
in the exposed esophageal submucosa adhering to the adjacent descending thoracic aorta,
may portend a more difficult esophagectomy;
especially with reoperations, bleeding from the
spleen may occur during the upper abdominal
gastric mobilization as left upper quadrant adhesions are divided. It has long been my practice
in these operations to confront the gastric fundus
mobilization and division of the high short gastric vessels as soon as possible after opening the
abdomen while the surgical team is at its freshest
and inadvertent splenic injury due to less likely
retraction. As the dissection is carried superiorly through the diaphragmatic hiatus and the
esophageal mobilization commenced, especially
in those who have had a prior esophagomyotomy,
narrow Deaver retractors should be placed into
the hiatus and sharp dissection of the esophagus
from the aorta under direct vision carried out.
Blunt dissection of the esophagus adherent to the
aorta may have dire consequences. In the patient
with a megaesophagus of achalasia, deviation of
the “sigmoid” esophagus into the right chest is
common, and not only dissecting into the right
chest but also beneath the azygos vein may be
hazardous.
The presence of mediastinal calcification
due to old granulatous disease on the preoperative chest radiograph and CT scan, particularly
in the subcarinal region, may be the harbinger of
potential bleeding during the transhiatal esophageal mobilization in this area. While such calcification per se does not preclude a THE, if the
surgeon encounters increased difficulty mobilizing the subcarinal esophagus, there must be a low
tolerance to convert to an open thoracotomy and
free the esophagus from the mediastinum under
direct vision.
Portal hypertension is a relative contraindication to esophagectomy and has been responsible twice for rare massive intraoperative
abdominal bleeding in our patients. The author
regards the presence of ascites from liver disease
as an absolute contraindication to esophagectomy. Even if untoward bleeding does not occur,
venous congestion of the mobilized stomach due
to portal hypertension may have devastating consequences if an esophagogastric anastomosis is
attempted.
Finally, it has been the personal observation
of the author that obese, “soft,” often elderly
women have experienced the preponderance of
intraoperative massive bleeding during a THE,
perhaps being more prone to an azygos vein tear
because of general tissue laxity. Such a body habitus or tissue strength does not preclude a THE,
but should alert the surgeon to the need to proceed cautiously.
General Considerations
The patient is positioned supine, the neck extended by placing a small rolled sheet under
the scapulae, and the head turned to the right
and supported on a soft head ring. The operative field is wide and includes the skin of the
neck, chest, and abdomen from the angle of the
394 Transhiatal Esophagectomy—Intraoperative Disasters
mandible superiorly to the pubis inferiorly and
anteriorly to both mid-axillary lines. There must
be adequate room to place a chest tube low in
the anterior axillary lines as indicated. Two suction lines with Yankauer suckers are routine, one
near the patient’s head and the other at the lower
end of the table. After the abdominal phase of the
operation and before beginning the transhiatal
esophageal mobilization, the Yankauer sucker
at the head of the table is removed and replaced
with a longer 28 Fr Argyle Saratoga sump catheter. This catheter is inserted into the posterior
mediastinum through the cervical wound after
each phase of the esophageal mobilization (posterior, anterior, and lateral) and the mediastinum
inspected through the hiatus to establish that excessive bleeding is not occurring. As a general
rule, the operation commences with mobilization
of the stomach through the upper midline abdominal incision. Exposure and division of the high
short gastric vessels are carried out first, when
the operative team is fresh, and untoward traction
on the left upper quadrant retractor with resultant
injury to the spleen is less likely to occur. Splenic
injury necessitating a splenectomy has occurred
in approximately 4
cially in those who have had prior fundoplications that must be taken down if the stomach is
going to serve as an esophageal replacement and
reach to the neck for a construction of a CEGA.
The need for a splenectomy for control of bleeding is uncommon, but when required, especially in a “re-do” abdomen, care must be taken to
preserve the integrity of the right gastroepiploic
artery, the primary blood supply of the gastric
esophageal substitute. In patients undergoing
a THE for a distal esophageal Barrett’s adenocarcinoma occurring in association with a large
paraesophageal hiatal hernia, care must be taken
to deliver the greater curvature of the stomach
out of the hiatus before commencing division of
what appears to be the high short gastric vessels.
It is easy in such patients to mistakenly divide the
right gastroepiploic artery erroneously felt to be a
short gastric vessel.
% of our THE patients,
espe-
Anesthetic Considerations
An epidural catheter for postoperative analgesia,
a standard endotracheal tube, and a Foley catheter
are routinely used. As indicated above, the patient
is positioned supine. Two large bore peripheral
intravenous lines and a radial artery catheter for
continuous monitoring of the blood pressure are
placed and well secured, and the arms are padded
and placed at the sides. Although the anesthetist
may feel uncomfortable about not having direct
access to the IVs intraoperatively, this positioning gives the surgeon and his assistant optimal
access to the neck, chest, and abdomen from both
sides of the table. To avoid prolonged hypotension from cardiac displacement, the surgeon and
the anesthesiologist both watch the monitored
blood pressure together while the surgeon’s hand
is in the posterior mediastinum performing the
transhiatal esophageal mobilization. Intraoperative monitoring of urinary output is important in
these patients with impaired swallowing, many
of whom have had preoperative bowel prep, as
hypotension due to low intravascular volume is
common.
During performance of the transhiatal esophageal mobilization, constant communication between the surgeon and the anesthetist is crucial.
As the hand is advanced upward into the mediastinum through the diaphragmatic hiatus, both
the surgeon and the anesthetist must monitor the
radial artery blood pressure in order to minimize
untoward hypotension associated with displacement of the heart by the surgeon’s hand. If the
surgeon’s hand is kept well posteriorly against
the spine, hypotension from anterior displacement of the heart is less. After 5–10 s of hypotension in the patient who is not hypovolemic, the
blood pressure should quickly return to the normal range within seconds of removing the hand
from the mediastinum. This is NOT the time for
the anesthesiologist to be correcting hypotension
with pressor agents. Persistent hypotension
after the surgeon’s hand is withdrawn from the
mediastinum signals either the need for volume
replacement or unrecognized mediastinal hemorrhage, not the need for pressors.
40 M. B. Orringer
Conduct of the Operation
It cannot be overemphasized that THE is not a
random wrenching of the esophagus from the
posterior mediastinum. The operation has component parts that have been well described elsewhere [14] and will only be briefly mentioned
here:
1. the abdominal phase: exploration, assessment
of the suitability of the stomach as an esophageal replacement, gastric mobilization, a
Kocher maneuver, pyloromyotmy, and insertion of a feeding jejunostomy tube;
2. the cervical phase: mobilizing and encircling
the cervical esophagus, blunt dissection of the
upper thoracic esophagus in the superior mediastinum;
3. the mediastinal dissection of the esophagus
(to be discussed further below);
4. preparation of the gastric conduit, transposition through the posterior mediastinum, and
abdominal wound closure;
5. the cervical esophagogastric anastomosis.
Considerations about potential major intraoperative bleeding or airway injury are related to
the mediastinal dissection of the esophagus. The
dissection begins in the abdomen through the
diaphragmatic hiatus as the surgeon palpates
the esophagus to assess its mobility. Fixation to
the spine, descending thoracic aorta, or the airway is a “red flag” that a persistent attempt at
resecting the esophagus transhiatally may end in
disaster. In the typical case, however, the surgeon
inserts one hand through the diaphragmatic hiatus posterior to the esophagus. This hand is advanced superiorly along the prevertebral fascia,
constantly against the spine to minimize anterior
displacement of the heart and untoward hypotension (Fig. 4.1). Simultaneously, the encircled
cervical esophagus is retracted anteriorly as a
“sponge-on-a-stick” is advanced through the cervical incision and down into the superior mediastinum dissecting the esophagus free from the
prevertebral fascia. Eventually the stick sponge
being advanced downward into the mediastinum
from “above” meets the fingers inserted through
the hiatus from “below,” and the first phase of
the posterior mediastinal “tunnel” is created
Fig. 4.1 The transhiatal esophageal mobilization begins
posteriorly, the surgeon’s hand inserted through the hiatus
with the volar aspect of the fingers sweeping the esophagus away from the prevertebral fascia and a similar posterior dissection of the upper thoracic esophagus through
the cervical incision. (Reproduced with permission from
[9] © Elsevier)
(Fig. 4.2). The 28 French Argyle Saratoga sump
catheter is inserted through the cervical incision
into the mediastinum along the spine, is used to
evacuate blood and assess for unusual bleeding,
and is then removed. The posterior dissection
of the esophagus is generally through relatively
avascular tissue planes.
Anterior dissection of the esophagus through
the hiatus is a mirror image of the posterior dissection. The esophagogastric junction is retracted
inferiorly by gentle downward traction on the
mobilized stomach. The surgeon’s hand is placed
against the anterior surface of the esophagus
palm downward and is advanced superiorly into
the mediastinum, gently dissecting the esophagus
from the posterior pericardium and then the carina (Fig. 4.3). In the neck, the cervical esophagus is retracted superiorly and laterally as two
fingers dissect progressively downward along
the anterior surface of the esophagus, mobilizing
it away from the posterior membranous trachea
(Fig. 4.4). The force of the dissection, no matter
414 Transhiatal Esophagectomy—Intraoperative Disasters
Fig. 4.2 A “half-sponge-on-a-stick” is advanced down-
ward through the cervical incision along the prevertebral
fascia until it can be palpated by the fingers inserted from
“below” through the hiatus, thereby establishing the first
portion of the posterior mediastinal tunnel. (Reproduced
with permission from [9] © Elsevier)
how gentle, most be directed posteriorly to avoid
a tear of the airway. When the fingers inserted
through the cervical wound meet those inserted
through the hiatus, the “anterior tunnel” is complete, and the Saratoga sump catheter is again inserted to monitor for untoward bleeding and then
removed. Lateral periesophageal attachments are
divided between long (13ʺ) right-angle clamps
inserted through the hiatus and ligated, minimizing the “blunt” dissection.
With the anterior and posterior esophageal attachments now divided, the cervical esophagus
is progressively elevated out of the neck wound
as the lateral attachments of the upper thoracic
esophagus are swept away by blunt dissection (Fig. 4.5). This results in an approximately
5–8 cm length of circumferentially mobilized
upper thoracic esophagus. The hand-inserted
palm downward through the diaphragmatic hiatus is advanced upward along the anterior surface
Fig. 4.3 Anterior dissection of the esophagus is per-
formed as a “mirror image,” this time with the volar aspects of the finger against the anterior esophageal wall.
The posterior membranous trachea is vulnerable to injury
as the esophagus is mobilized away from the airway from
“below” and “above.” (Reproduced with permission from
[9] © Elsevier)
of the esophagus until the circumferentially
mobilized upper thoracic esophagus is identified by palpation (Fig. 4.6). The esophagus is
“trapped” against the spine by the fingers, and
with a progressive downward “raking” motion,
the remaining lateral esophageal attachments
and vagal branches are gently avulsed (Fig. 4.7).
Larger vagal branches can be delivered downward until visible through the hiatus and divided
using a long right-angle clamp and electrocautery
(Fig. 4.7 inset). With mobilization of the thoracic
esophagus now completed, the cervical esophagus is elevated several centimeters out of the
neck wound, the cervical esophagus divided with
a stapler (Fig. 4.8), and the esophagus drawn
downward and out of the mediastinum by gentle
traction on the stomach.
While it is tempting at this point to “admire”
the resected esophagus and for all present at the
table to palpate a tumor if present, this should
be resisted. As soon as the esophagus is out of
the posterior mediastinum, a Deaver retractor is
42 M. B. Orringer
Fig. 4.4 The attachments between the trachea and esoph-
agus are generally flimsy and avascular. As the dissection
proceeds, the fingers must exert their force posteriorly,
away from the membranous trachea, to avoid a tear. (Reproduced with permission from [9] © Elsevier)
Fig. 4.5 After establishing the anterior and posterior
esophageal “tunnels,” the additional mobility of the esophagus allows it to be elevated out of the cervical wound for
several centimeters by one finger “hooked” beneath it as
the index finger of the opposite hand sweeps the lateral
esophageal attachments aside. The upper thoracic esophagus is thus entirely circumferentially mobilized and is released back down into the upper mediastinum for the next
phase of the esophageal mobilization. (Reproduced with
permission from [9] © Elsevier)
inserted into the hiatus and an inspection made
for unusual bleeding and entry into one or both
pleural cavities (requiring chest tube placement).
Routinely, one or two large abdominal laparotomy pads are packed through the hiatus into
the mediastinum with long forceps, and while
protecting the recurrent laryngeal nerve in the
cervical wound, two narrow thoracic packs are
advanced downward into the superior mediastinum against the packs placed from below. All
packs placed into the mediastinum through either
the abdominal or thoracic incisions are “tagged”
with a hemostat to avoid inadvertent intraoperative loss and an incorrect count at the end of the
case. Once the mediastinum has been packed
to allow both pressure and natural hemostatic
mechanisms to control any oozing that might be
present, and any required chest tubes have been
inserted in the appropriate anterior axillary lines
and connected to drainage, attention can then
be turned to removing the esophagus and upper
stomach and fashioning the gastric conduit.
Bleeding Scenarios During THE
In the rare situation in which sudden unexplained, prolonged severe hypotension occurs
during with the esophageal mobilization, even
after the surgeon removes his/her hand from the
posterior mediastinum, unrecognized bleeding
must be suspected. If there is no sign of excessive bleeding from the hiatus or the cervical incision, bilateral 28 French chest tubes should be
placed quickly low in the anterior axillary lines,
advanced to the apices, connected to suction, and
an assessment made for internal bleeding into
a chest cavity by evaluating chest tube output.
Intravascular volume replacement is achieved
through two large bore peripheral IVs placed
routinely in these operations. If on retraction of
434 Transhiatal Esophagectomy—Intraoperative Disasters
Fig. 4.7 Lateral esophageal attachments and smaller
vagal fibers are avulsed by a downward “raking” motion
of the fingers that are kept against the spine. Inset—More
substantial vagal fibers can be pulled downward until visible through the retracted hiatus and divided using a long
right-angle clamp and electrocautery. (Reproduced with
permission from [9] © Elsevier)
Fig. 4.6 The hand inserted through the diaphragmatic
hiatus is advanced superiorly behind the trachea until
the segment of completely circumferentially mobilized
upper thoracic esophagus can be identified by palpation
and “trapped” against the spine between the index and
middle fingers. (Reproduced with permission from [9] ©
Elsevier)
the hiatus and inspection of the mediastinum, it
is determined that appreciable “high” mediastinal
bleeding is occurring and draining into the chest
through an opening in the pleura (generally on the
right and from a torn azygos vein), the posterior
mediastinum should be packed quickly through
the hiatus with two large laparotomy packs from
“below” and two narrow thoracic packs placed
behind the esophagus through the cervical wound
(Fig. 4.9) (The recurrent laryngeal nerve in the
tracheoesophageal groove is protected with the
fingers as the packing is carried out.) (Fig. 4.9
inset). The abdomen is quickly closed with 4–5
through and through No. 2 sutures and the incision covered with an adhesive surgical drape
(Fig. 4.10 inset). Similarly, the cervical wound is
quickly closed with a running nylon suture and
covered with an adhesive surgical drape. The patient is turned to the left side, positioned and padded for a right posterolateral thoracotomy. The
chest is entered through a fifth intercostal space
incision and the bleeding site identified and controlled (usually by ligating and suture-ligating the
torn azygos vein). Exposure may be facilitated by
palpating the carina and having the anesthesiologist advance the endotracheal tube as it is guided
into the left mainstem bronchus by the surgeon’s
fingers. Single lung ventilation of the left lung
can then be instituted. If the esophagus has not
been removed yet, the esophageal mobilization
is completed. The patient is then turned supine
once again, positioned as before, and the esophageal replacement with the stomach completed