Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4110_Библиотеки_им_академика_М_И_Перельмана

preserved.

After the division of the gastrohepatic omentum, the esophagus was mobilized first by dissecting out the right crus and taking

down the phrenoesophageal ligament, making sure to preserve the peritoneal lining of the right crus. The areolar plane

performed high in the mediastinum to the level of the inferior pulmonary veins to help re-establish adequate intraabdominal

Attention was then turned to the mobilization of the fundus and the division of the short gastric vessels. With the traction of

gastrosplenic omentum and countertraction of the stomach, the short gastric vessels were ligated with a harmonic scalpel along

injury to the spleen. Gastrosplenic attachments were carefully ligated. Retrogastric attachments were also taken down, and a

To help facilitate precise identification of the gastroesophageal junction, the gastric fat pad was dissected anteriorly off the

stomach and distal esophagus, taking care to preserve the anterior vagus nerve. A retroesophageal window was then

developed between the esophagus and posterior vagus nerve through which a Nissen fundoplication would be performed.

achieved through laparoscopic wedge Collis gastroplasty. A 54-French bougie was placed transorally into the stomach under

In preparation for a “floppy” Nissen fundoplication, a 54-French bougie is placed transorally into the stomach under direct

the right side. A “shoe-shine” maneuver was then performed with the created wrap to ensure adequate mobility without twists

cm apart to prevent slippage of the wrap.

device, multiple serial interrupted horizontal mattress of #0 Surgidac sutures were placed between the stomach and the anterior

abdominal wall over a distance of about 10 cm, spaced 2 cm apart.

adequate tissue integrity and mobility. [Due to the enlarged hiatus and significant tension with the approximation of the crura,

of the diaphragm. The diaphragm was noted to become relaxed and bulged into the peritoneal cavity. The pigtail catheter was

then secured to the skin and placed to drainage after the closure of the hiatus.] The crura were reapproximated with 2 (or 3)

the hiatus was re-evaluated and noted to have a patulous anterior space. A single stitched was then placed anteriorly in the

upper aspect of crura.] Care was taken to avoid artificially creating an angulation of the esophagus at the hiatus. At the

completion of the hiatal closure, a grasper was easily passed through the hiatus and the closure did not appear tight.

3. General endotracheal anesthesia

8. Kocher maneuver

13. Transhiatal mobilization of entire esophagus

1. Unrecognized progression of disease

2. Unrecognized replaced left hepatic artery

3. Splenic injury

4. Inadequate/unhealthy conduit (ischemic, traumatized, or narrowed), need for alternate conduit (colon, jejunum)

5. Control of left gastric artery

6. Inadequate duodenal mobilization

7. Inadvertent pyloric mucosal injury

8. Mediastinal bleeding (azygous vein injury)

9. Injury to the membranous trachea

10. Recurrent laryngeal nerve injury

11. Torsion of conduit

Template Dictation

Preoperative diagnosis: [INDICATION – high grade dysplasia, esophageal squamous or adenocarcinoma] [with or without

neoadjuvant chemoradiation therapy]

2. Transhiatal esophagectomy

5. Jejunostomy tube placement

6. +/- chest tube placement

Attending Surgeon: [BLANK]

Secondary Surgeon: [BLANK]

Assistants: [BLANK]

the recurrent laryngeal nerve resulting in hoarseness, the airway, blood vessels, spleen resulting in a splenectomy, thoracic

from X cm to X cm. There [was X cm of/no] extension onto the stomach. The gastroscope was advanced into the stomach and

The patient was positioned supine with a folded blanket under the shoulders. The head was turned to the right and supported on

a head ring. The arms were padded and tucked at the sides. The skin of the neck, chest and abdomen was prepped and draped.

The peritoneal cavity was entered through a supraumbilical midline incision. The triangular ligament of the liver was divided

with cautery, and the left lobe of the liver was padded and retracted to the right. An upper hand self-retaining table mounted

the stomach. After identifying the course of the right gastroepiploic artery, and beginning at the midpoint of the greater

and a fine tipped mosquito clamp. The duodenal mucosa [WAS/WAS NOT] entered during this dissection. [Due to a mucosal

injury, a pyloroplasty was performed opening the pylorus longitudinally. The pyloroplasty was closed transversely in 2 layers

A #14 French rubber jejunostomy tube was inserted 4-6 inches beyond the ligament of Treitz and was secured in place with

resection with the esophagus and proximal stomach. During the mediastinal dissection, arterial blood pressure was monitored

with a radial arterial line to avoid prolonged hypotension due to displacement of the heart. The dissection was carried to the

was completed using a combination of finger dissection and dissection with a sponge stick. Blood was evacuated from the

significant mediastinal bleeding was encountered. Both sides of the mediastinal pleura were inspected for injury. Entry into

both pleura [WAS/WAS NOT] identified [28F straight chest tubes were placed bilaterally, secured to the skin with #2-0

field. The position of the stomach in the neck wound was maintained by packing a small moistened gauze into the thoracic inlet

gastric fundus was performed using the 3.8 mm Endo-30 GIA stapler. Two lateral suspension sutures of #4-0 Vicryl were

anastomosis. Muscle fascia was loosely reapproximated with interrupted #3-0 Vicryl, and the skin edges were reapproximated

New York Presbyterian –Weill Cornell Medical Center

Essential Operative Steps

2. General anesthesia, endotracheal tube, lines and monitoring

3. Flexible Bronchoscopy

4. Esophagogastroduodenoscopy

5. Double lumen endotracheal tube

9. Ligate thoracic duct

11. Close thoracotomy in layers

12. Turn patient supine.

17. Greater omentum resected, leaving the gastroepiploic arcade.

Beginning inferiorly travelling along the greater curvature, tissues and short gastric vessels were divided outside of

the right gastroepiploic arcade to completely free greater curvature.

19. Dissect gastroesophageal junction. Previously placed Penrose drain is grasped and used for retraction.

20. Divide left gastric vessels

21. Take down remaining retrogastric attachments

and grasp the previously placed Penrose drain at the thoracic inlet.

28. Construct a 4cm wide gastric conduit based on the line of the short gastric vessels, beginning at level of Crow’s foot

and extending to Angle of His. Oversew the staple line.

30. End-to-end two layer handsewn anastomosis using interrupted 3-0 Vicryl for the inner layer and 3-0 PDS for the

32. #10 flat Jackson-Pratt placed into the neck incision,

35. Abdominal fascia and incision closed in layers

36. Exchange double lumen for single lumen endotracheal tube

37. Toilet bronchoscopy and assess airways for thermal injury.

1. Anastomotic complications (i.e., leak/dehiscence and strictures)

3. Recurrent nerve injury, resulting in aspiration and impaired ability to swallow.

4. Chylothorax from thoracic duct injury

5. Gastric outlet obstruction

2. Cardiovascular complications including arrhythmias and myocardial infarction

5. Infectious complications including urinary tract infection and line infections.

6. Wound complications including infection and dehiscence.

7. Gastrointestinal complications including ileus, colitis, perforation, volvulus, and obstruction.

Drains: 28 Fr right chest tube, #10 Jackston-Pratt drain, 14 Fr red rubber feeding jejeunostomy tube

tumor by EUS and PET/CT. The patient had a favorable response to neoadjuvant chemoradiaiton therapy was deemed an

appropriate candidate for esophagectomy.

In preparation for surgery, the patient underwent a cardiopulmonary evaluation which included a negative stress test and

Description of Procedure:

tube. The trachea was normal. The carina was sharp. Examination of the right and left mainstem bronchi and all lobar and

segmental bronchi bilaterally down to the level of the subsegments failed to reveal any endobronchial abnormalities such as

airways bilaterally. The normal anatomy was otherwise present. The flexible bronchoscope was withdrawn.

gastric antrum and fundus were normal. The incisura was sharp; the stomach distended normally. The gastroscope was

Next, the patient's single-lumen endotracheal tube was exchanged for a double lumen endotracheal tube by anesthesia, and

abnormalities. The inferior pulmonary ligament was divided to the level of the inferior pulmonary vein using electrocautery. A

mediastinal pleura anterior to the esophagus was divided between the inferior pulmonary vein and azygous vein. An

avascular window was created around the azygous vein, and the vein divided with a endo-GIA vascular load stapler. The

level of azygos vein, the esophagus was circumferentially dissected free from the surrounding soft tissues. A Penrose drain

We then turned our attention back to the lower thoracic esophagus and completed the anterior portion of the dissection. The

periesopheal lymphatics were dissected off the pericardium. The dissection was continued cephalad, dissecting the

periesophageal lymphatics off the bronchus intermedius. The subcarinal lymph node packet was removed en bloc with the

esophagus. The periesophageal tissues were then dissected off the right mainstem to the level of the azygous vein. We then

turned our attention to the posterior dissection plane and took down the periesophageal lymphatics from the level of the

The dissection was continued inferiorly to and below the level of the hemidiaphragm. At the hiatus, the muscle fibers of the

crura were identified. Dissection was continued until nearly circumferential intraperitoneal access was achieved. The

the hiatus and into the peritoneal cavity.

minimize the risk of recurrent laryngeal nerve injury. The Penrose drain was tucked into the thoracic inlet to facilitate

identification of the proper dissection plane from the cervical dissection.

was made, a #28 French chest tube (with extra drainage holes cut into it) was inserted through a small incision in the anterior

axillary line at approximately the 7

intercostal space. The chest tube was positioned posteriorly to the apex and secured in

place using a #0 silk suture. The right hemithorax was then copiously irrigated with antibiotic irrigation. Number 2 Vicryl

neck, chest and entire abdomen were prepped and draped in the usual sterile fashion. A midline incision from the xiphoid to

the supraumbilical area was used to gain access atraumatically to the peritoneal cavity. The xiphoid process was resected at

an upper hand retractor. The left lobe of the liver was gently folded on itself, covered with a moist laparotomy pad, and a

was grasped and used for retraction purposes.

The transverse colon was mobilized from the greater omentum using a combination of electrocautery and the ligasure device in

taking care to leave the gastroepiploic arcade, which was readily palpable, undisturbed. This omentectomy specimen was sent

The greater curvature of the stomach was cautiously grasped with a gauze sponge, being certain that the right gastroepiploic

arcade was protected at all times. The lesser sac was taken entered, and the short gastrics were taken down all the way to the

Angle of His using a Ligasure. The remaining retrogastric and retroesophageal attachments were taken down. The left gastric

vessels were left intact. We then completed the caudal dissection along the greater curvature of the stomach. The antropyloric

Next, a pyloromyotomy [OR PYLOROPLASTY] was performed. Electrocautery was used to begin to divide the muscle

of Treitz, a freely mobile loop of jejunum was chosen for jejunostomy tube insertion. Concentric pursestring sutures of 3-0

advanced distally into the jejunum. The pursestring sutures were secured. The jejunostomy tube was Witzled at the

abdominal wall in four quadrants using interrupted 3-0 Vicryl sutures. The jejunostomy tube was sutured at its skin exit site

using an #0 Ethibond suture. Antiobstruction stitches were placed 5 cm proximal and 5 cm distal to the jejeunostomy using 3-0

Vicryl sutures. After assuring that it flushed easily, the jejeunostomy was capped.

NECK DISSECTION AND ANASTOMOSIS

An oblique incision was made in the neck paralleling the anterior aspect of the left sternocleidomastoid muscle. The incision

with #0 Vicryl ties and then divided using electrocautery. The sternocleidomastoid and carotid sheath were retracted laterally,

prevertebral fascia. The previously placed Penrose drain at the thoracic inlet was grasped and brought up into the wound.

Staying directly on the esophagus, the esophagus was mobilized off the trachea to the level of the cricopharyngeus using

An ampule of glucagon was then administered by Anesthesia. Palpation through the esophageal hiatus confirmed dilation to

four fingers width. After adequate circulation time of glucagon, the nasogastric tube was withdrawn by anesthesia to just

withdrawn from the abdomen, thereby pulling the silk suture through the mediastinum. An Allis clamp was placed on the

proximal esophagus to maintain appropriate orientation. The suture in the abdomen was disconnected from the specimen. The

left gastric vessels were divided at their takeoff with an endo GIA vascular load stapler. Beginning on the cardia and

of an endo GIA purple load stapler. At approximately the level of the 3rd arcarde along the lesser curvature, the staple firings

were angled towards the lesser curvature. The lesser curvature vessels were divided using an endo GIA vascular load

pathology, and frozen sections confirmed microscopically negative margins for metaplasia, dysplasia, and carcinoma. The

entire staple line of the newly created gastric conduit was oversewn using running 3-0 Vicryl sutures. The end of a silk suture

approximately 20 mL. An arthroscopy bag was placed around the Foley and tied proximally to the balloon. The bag was cut to

an appropriate length. At this point, the gastric conduit was inserted into the arthroscopy bag. Proper orientation was

maintained on the gastric conduit. The Foley catheter was placed to suction and the arthroscopy bag sealed down around the

gastric conduit. While maintaining continuous suction, the bag was carefully advanced through the mediastinum, thereby

atraumatically delivering the gastric conduit in appropriate orientation through the mediastinum and out through the cervical

incision. The arthroscopy bag was removed. The conduit appeared pink and healthy.

The staple lines from the remnant esophagus and gastric conduit were resected. An end-to-end two layer handsewn

separate stab incision in the neck, positioned posterior to the anastomosis, and secured to the skin using a 3-0 nylon suture.

Vicryl subcuticular suture. Steri-Strips and sterile dressings were applied. The double-lumen endotracheal tube was

endotracheal tube. A moderate to large amount of mucopurulent secretions was again suctioned from the airways bilaterally.

There was no evidence of airway injury. The flexible bronchoscope was withdrawn.