clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

Minimally Invasive Esophagectomies

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STEP 2

Endodissection

The mediastinal endodissector is then assembled and inserted into the upper medi-

astinum. This instrument features a tissue dilator at the tip, a 15-degree Hopkins fiber-

optic device and a working channel for one 5-mm laparoscopic instrument. The tissue

dilator is anatomically designed so that it can “ride” on the esophageal surface and opens

an anterograde dissection space of 2–3cm in the mediastinum. The tissue dilator of the

mediastinoscope can be freely rotated 360degrees. For full operation, the medi-

astinoscope is connected to a video camera, a xenon light source, and a flushing/suction

device.

It is normal that the first steps of endoscopic dissection of the retrotracheal space are

difficult due to the limited initial vision and the anatomical narrowing of the thoracic

inlet. Microinstruments such as scissors, forceps or a coagulation/suction instrument

as well as ultrasonic shears can be used through the working channel of the medi-

astinoscope.

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SECTION 2

Esophagus, Stomach and Duodenum

STEP 3

Endodissection: mediastinoscopic anterior view

Minimally Invasive Esophagectomies

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STEP 4

Endodissection: mediastinoscopic posterior view

The back wall and the right surface of the esophagus usually present no major

difficulties, and opening of the mediastinal pleura is not usually critical. Finally,

the esophagus should be circumferentially mobilized and contact between the ab-

dominal team and the cervical team should be made. The cervical team assists during

the phase of en bloc dissection of the infracarinal esophagus by providing light and

suction from above. This can be helpful especially in large tumors. Finally, the cervical

esophagus is divided by a longitudinal stapler device and retracted into the abdominal

cavity. The mediastinal procedure is completed by control of hemorrhage and removal

of visible lymph nodes for supplementary staging information.

Minimally Invasive Esophagectomies

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STEP 6

Reconstruction

Routinely, we reconstruct the gastrointestinal passage by pull-through of a narrow

gastric tube in the anterior or the posterior mediastinum. Only in younger patients

with good prognosis is a reconstruction with colon accomplished.

See chapter on “Subtotal Esophagectomy: Transhiatal Approach” for standard

postoperative investigations.

The common type of diverticula (Zenker’s) is not actually of esophageal origin,

but arises from the relatively bare triangle of mucosa located between the inferior

pharyngeal constrictors and the cricopharyngeal muscle (Killian’s triangle).

Zenker’s diverticula are 10 times more common than other esophageal diverticula.

Zenker’s diverticula are so called false diverticula and are classified according

to Lahey:

Stage I:

No symptoms, local mild inflammation

Stage II:

Dysphagia and regurgitation

Stage III:

Esophageal obstruction, dysphagia, and regurgitation

Indications and Contraindications

Progress over time. Treatment is recommended for patients who have moderate

Indications

■

to severe symptoms/complications (pneumonia or aspiration)

Severe physical constitution

Contraindication

■

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SECTION 2

Esophagus, Stomach and Duodenum

Procedure

Access

The patient is placed in a supine position with the head rotated to the right.

STEP 1

Approach

The approach to the diverticulum for surgical therapy comes through a left cervical inci-

sion (most Zenker’s diverticula present on this side) at the level of the cricoid cartilage

on the anterior aspect of the sternocleidomastoid muscle just above the clavicle. The

anatomical overview of the access to the cervical esophagus is given in the figure.

STEP 2

Dissection

Dissection is performed between the medial aspect of the sternocleidomastoid muscle,

which is pulled laterally, and the strap muscles by retracting the carotid sheath laterally

and preserving the recurrent laryngeal nerve. The omohyoid muscle may be either

retracted or transected. The thyroid gland is mobilized and vessels are dissected.

Zenker’s Diverticula: Open Approach

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STEP 3

Mobilization of the esophagus and the diverticulum

The esophagus is mobilized from the prevertebral fascia, and the diverticulum is

evident posterior to the esophagus (a tube may be inserted in the diverticulum for

better identification). Large diverticula may extend into the mediastinum, but gentle

traction and blunt dissection are sufficient to mobilize even the largest diverticula.

The figure shows the anatomy of the cervical diverticula.

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SECTION 2

Esophagus, Stomach and Duodenum

STEP 4

Preparation of diverticulum