clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer
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SECTION 2 |
Esophagus, Stomach and Duodenum |
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STEP 1 |
Thoracotomy and incision of the pleura along the resection line |
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Thoracotomy through the 5th ICS with skin incision from the apex of the scapula to the submammarian fold (A).
Two retractors are positioned stepwise. Single left lung ventilation is performed. The mediastinal pleura is incised along the resection line for the en bloc esophagectomy. Incision starts from the pulmonary ligament, circumcising the dorsal part of the right hilum of the lung and along the right bronchus. It follows the right main bronchus at the lateral margin of the superior vena cava up to the upper thoracic aperture. Then the incision line changes direction caudally along the right lateral margin of the spine, down to the diaphragm along the azygos vein. It is of the utmost importance to identify the right phrenic nerve (B).
A
B
Subtotal En Bloc Esophagectomy: Abdominothoracic Approach |
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STEP 2 |
Division of the pulmonary ligament |
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For exposure of the pulmonary ligament the lung is pushed cranially and laterally. All lymphatic tissue should be moved towards the esophagus. Care has to be taken not to injure the vein of the lower lobe of the right lung.
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SECTION 2 |
Esophagus, Stomach and Duodenum |
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STEP 3 |
Ligation of the azygos vein |
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The superior vena cava and the azygos vein are dissected. Suture ligation towards the vena cava and ligation of the azygos venal stump are performed.
Subtotal En Bloc Esophagectomy: Abdominothoracic Approach |
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STEP 4 |
Radical en bloc lymphadenectomy |
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Lymphadenectomy starts from the superior vena cava up to the confluence of the two vv. anonymae. Dissection of the bracheocephalic trunk and right subclavian artery is followed by dissection of the right vagal nerve and identification of the right recurrent laryngeal nerve. Caudal to the branching of the recurrent laryngeal nerve, the vagal nerve is transected and the distal part is pushed towards the en bloc specimen. Then lymphadenectomy is performed continuously along the dorsal wall of the superior vena cava (A).
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SECTION 2 |
Esophagus, Stomach and Duodenum |
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STEP 4 (continued) |
Radical en bloc lymphadenectomy |
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After having completed preparation of the superior vena cava, the trachea and the rightand right-sided main bronchus are completely freed from lymphatic tissue. The preand paratracheal fat and lymphatic tissue are dissected towards the esophagus (B).
Dissection of the retrotracheal lymph nodes is then performed. Injury of the membranaceous part of the trachea has to be carefully avoided while removing these nodes towards the esophagus (C).
Subtotal En Bloc Esophagectomy: Abdominothoracic Approach |
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STEP 4 (continued) |
Radical en bloc lymphadenectomy |
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Lymph node dissection continues with the upper paraesophageal lymph nodes (D). All intercostal veins that drain into the azygos vein are ligated and divided.
Lymphadenectomy of the subcarinal lymph nodes is then performed with dissection of the left main bronchus (E).
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SECTION 2 |
Esophagus, Stomach and Duodenum |
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STEP 4 (continued) |
Radical en bloc lymphadenectomy |
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Para-aortic lymphadenectomy is performed. The esophageal branches of the thoracic aorta have to be dissected very carefully and should be ligated with suture ligation (F).
Identification and careful dissection of the thoracic duct is done with double ligations directly above the diaphragm and at the level of the main carina (G).
Subtotal En Bloc Esophagectomy: Abdominothoracic Approach |
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STEP 4 (continued) |
Radical en bloc lymphadenectomy |
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Mediastinal lymphadenectomy is completed with the removal of the left sided paraaortic and retropericardial lymph nodes, as well as the intermediate and lower lobe bronchus down to the esophageal hiatus (H).
After complete mobilization of the esophageal specimen, thoracic drainage is placed in the right thoracic cavity. After closure of the thoracic incision the patient is repositioned for the abdominal part.
For the abdominal and cervical parts: see the transhiatal approach.
Alternatively an intrathoracic anastomosis can be achieved (see chapter on intrathoracic anastomosis).
See chapter “Subtotal Esophagectomy: Transhiatal Approach” for standard postoperative investigations and complications.
Tricks of the Senior Surgeon
Abdominothoracic En Bloc Esophagectomy with High Intrathoracic Anastomosis
Asad Kutup, Emre F. Yekebas, Jakob R. Izbicki
Introduction
High intrathoracic anastomosis may be performed without compromising the oncologic requirements alternatively to collar anastomosis for treatment of intrathoracic tumors, i.e., if located distally to the tracheal bifurcation. The benefits of considerably shorter operating times are associated with the risk of developing devastating mediastinitis when anastomotic leakage occurs.
Indications and Contraindications
Indications |
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Thoracic esophageal carcinoma |
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Long distance peptic stricture, if transhiatal resection is not possible |
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See chapter on “Subtotal Esophagectomy: Transhiatal Approach” |
Contraindications |
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High risk patients |
Preoperative Investigation/Preparation for the Procedure
See chapter on “Subtotal Esophagectomy: Transhiatal Approach”.
Procedure
Access
■Helical positioning of the patient with 45° elevation of the right thorax and elevated arm
■Turning the table to the patient’s supine position for the abdominal part of surgery
■Turning the table to the left for the thoracic part of surgery
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STEP 1
STEP 2
STEP 3
SECTION 2 |
Esophagus, Stomach and Duodenum |
See Steps 1–3 and Step 5 of the chapter “Subtotal Esophagectomy: Transhiatal Approach”
See Steps 1–4 of the chapter “Subtotal Esophagectomy: Transhiatal Approach”
High intrathoracic anastomosis
Transection of the esophagus is carried out 5cm below the upper thoracic aperture over a Pursestring 45 clamp. Alternatively the esophagus is transected and a running suture (monofilament, 2-0) is applied as a pursestring suture.
Dilatation of the proximal esophageal stump with a blunt clamp is performed. The anvil of a circular stapler (preferably 28mm) is introduced into the esophageal stump and fixation is done by tying the pursestring suture.
Mobilization of the gastric tube through the diaphragmatic esophageal hiatus is performed, followed by resection of the apex of the gastric tube. This is usually longer than required. Then introduce the stapler into the gastric tube, and perforation of the wall at the prospective site of the anastomosis with the head of the stapling device (A).
In case of limited length of the gastric tube, the stapling device is inserted through a ventral gastrostomy and an end-to-end gastroesophagostomy is performed.
Connection with the anvil is followed by firing of the instrument (B).
Check for completeness of the anastomotic rings. The stapler is removed and closure and resection of the protruding part of the gastric tube are done with a linear stapler.
A nasogastric feeding tube is then inserted over the anastomosis and placed into the first jejunal poop for decompression and postoperative enteral feeding. Thoracic drainage is placed in the right thoracic cavity.
Alternatively, this elegant method can be performed in the same manner in the case of colonic interposition after esophagogastrectomy (C, D).