Fig. 15.1
The gastroepiploic arcade
Fig. 15.2
The left gastric artery. (Reprint with permission from Fisichella et al, Atlas of esophageal surgery, Springer, 2015)
Fig. 15.3
Hiatus with right crus and left crus
Fig. 15.4
Aorta, Pleura, azygos vein, thoracic duct, right and left mainstem
Fig. 15.5
Cervical esophagus, recurrent laryngeal nerve
15.1.3 Operation Step by Step
15.1.3.1 Positioning
Laparoscopic transhiatal esophagectomy is performed with the patient in dorsal lithotomy position, with the operating surgeon standing between the legs with assistants on either side.
The standard precautions for safe positioning are applied.
The patient has general anesthesia with endotracheal intubation, an arterial line for monitoring and either two large IV accesses or a central line (on the right side of the neck) (Fig. 15.6).
Fig. 15.6
Patient is in dorsal lithotomy position, with the operating surgeon standing between the legs with assistants on either side
Establishing pneumoperitoneum and trocar positioning.
The pneumoperitoneum is established either with Veress needle, optiview trocar or Hassan technique. The location for the first trocar is similar to the Nissen fundoplication except that it is a horizontal incision in the midline, as this incision will be later extended to a mini-laparotomy to construct the gastric pull-up.
The further trocars are placed in the upper abdomen in a standard laparoscopic Nissen fundoplication configuration. A diagnostic laparoscopy is performed to rule out any peritoneal metastasis, distal disease or liver metastasis (Fig. 15.7).
Fig. 15.7
Incisions or trocars placement
15.1.3.2 Part 1
The distal esophagus and all periesophageal tissue are then carefully mobilized and the dissection is extended proximally in a circumferential manner. This allows a first assessment of the resectability of the tumor. The operation can be still aborted after initial mobilization, if no safe plane can be encountered to either the aorta, or the pericardium, the airway or the inferior pulmonary vein. The pericardium is skeletonized anteriorly up to the carina. In a similar manner, the aorta is skeletonized posteriorly, and the parietal pleura laterally. The right and left crura are often incised to provide better exposure of the mediastinum (Fig. 15.8).
Fig. 15.8
Mobilization of the distal esophagus and all periesophageal tissue
15.1.3.3 Part 2
After completing this portion of the mediastinal dissection, the stomach is then mobilized preserving the epiploic arcade (Fig. 15.9).
Fig. 15.9
The epiploic arcade should be preserved
This is best started midway by defining the omentum on top of the transverse colon, then close to the colon and up to the inferior border of the spleen the dissection is performed with a harmonic scalpel. Then, similar to the dissection of the fundus for a laparoscopic fundoplication, but this time instead of close to the stomach the dissection is performed close to the spleen (cave splenic artery). After opening the pars flaccida the lesser sac is entered, the left gastric artery identified and a lymphadenectomy of the celiac trunk is performed. The left gastric artery is stapled of with a vascular staple load (white) (Fig. 15.10).
Fig. 15.10
The left gastric artery is stapled
15.1.3.4 Part 3
The cervical dissection is then performed through a left neck incision and the cervical esophagus is dissected down to the proximal extent of the previous mediastinal dissection.
The esophagus is then transected in the neck and removed transabdominally after the camera port is extended with a mini-laparotomy to 5 cm to accommodate the specimen. The stomach is then tubularized by sequential firings of a GIA 100 mm stapler, and the staple line is over-sewn to prevent lesions of the staple line when being pulled-up, as well as to prevent damage of the staple line to the airway or vascular structures in the chest. The perfusion of the gastric pull-up is then tested with laser-assisted angiography (Spy-System, Novadaq, Toronto), and the area of good perfusion marked with a stitch (Fig. 15.11).
Fig. 15.11
Perfusion can be assessed with laser-assisted fluorescence angiography using the Spy-system (Novadaq, Toronto)
A chest tube is then passed through the posterior mediastinum, attached to the gastric conduit, and gently withdrawn to pull the conduit up into the neck (Fig. 15.12).
Fig. 15.12
Pulling up gastric conduit into the neck: the top of half of a bulb syringe connected to a chest tube is used to pull-up safely the gastric conduit
Adequate vascular supply of the conduit and the esophagus is confirmed, and a single-layer interrupted hand-sewn anastomosis is constructed. Additionally, a jejunostomy feeding tube is routinely placed for post-operative nutritional supplementation. Pyloroplasty is not performed for any patients undergoing LTE.
15.2 Results and Discussion
The laparoscopic transhiatal approach was first described by DePaula et al. in 1995, with several subsequent reports regarding this technique [1–3]. The transhiatal approach avoids the complications of directly accessing the thorax. For some surgeons this is a perceived lack of mediastinal exposure that could potentially compromise the radial resection margins and lymphadenectomy. Although there was initial concern over the oncological feasibility of minimally invasive techniques, a systematic review by Dantoc et al. reported higher median lymph node yield for MIE compared to open techniques (16 vs. 10), as well as no significant difference in 5-year survival [4].
In our recently published study we showed that laparoscopic transhiatal esophag -ectomy (LTE) had comparable results compared to open esophagectomies, but with the benefits of laparoscopic surgery [5]. In summary our study results: Charts were reviewed to identify all patients who had undergone LTE (33 consecutive patients) for esophageal cancer from a period of July 2008 to July 2012. Data were analyzed and compared to a historical cohort of esophageal cancer patients who underwent open transhiatal esophagectomy (OTE, 60 patients) and en-bloc esophagectomy (EBE, 139 patients) at the same institution from November 2002 to November 2009, to investigate perioperative outcomes, lymph node harvest, and overall survival.
Prevalence of comorbidities was significantly higher in the LTE and OTE groups than EBE (p = 0.01), with a higher incidence in all subgroups except prevalence of diabetes.
Additionally, the percentage of patients with positive nodes was similar among all groups (p = 0.65), although the number of lymph nodes resected was lower for the LTE group (22) than the OTE and EBE groups (p < 0.0001). Recurrence was similar among all groups (p = 0.9), with no significant differences between the ratios of systemic and locoregional recurrence between the groups (p = 0.24). The LTE group had a conversion rate of 6.1 % (2/33), with one conversion being due to the inability to clearly identify the left gastric vessels due to adhesions. The other conversion was due to difficulty with port placement and maintaining proper insufflation secondary to a previous abdominal wall reconstruction.
The average operative time was similar among LTE and OTE groups (274 and 275.5 min), and significantly shorter than the EBE group (415 min) (p < 0.0001). The presence of minor operative complications among the three groups was similar (p = 0.36), but major complications (defined as those requiring intervention other than conservative management, a prolonged hospital stay, or any anastomotic complication) were significantly less common in the LTE group (p = 0.04). The median LOS was significantly lower for the LTE group at 10 days, compared to the OTE and EBE groups, at 13 days and 15 days, respectively (p < 0.0001).
Median follow-up was 26 months (2–55 months) for the LTE group. Using the Kaplan-Meier method, overall survival was not significantly different between the groups, with a median survival at 24 months of 70 %, 65 %, and 65 % respectively (p = 0.65).
The number of centers employing MIE continues to rise, as well as the overall percentage of patients undergoing MIE compared to open repair [6]. Due to the difficulty of randomization, only one trial has been published to date. This study compared open transthoracic with minimally invasive transthoracic esophagectomy, showing lower rates of pulmonary complications and shorter hospital stay in the MIE group, with equivalent lymph node yield between the two arms [7].
In their selected series of LTE compared to laparoscopic and thoracoscopic two-field esophagectomy, Benzoni et al. showed shorter operative times, shorter ICU and overall stay, and a trend towards better survival in the LTE group [8]; although this was limited by a small number of patients.
15.2.1 Conversion Rate and Learning Curve
Depending on the type of MIE employed, conversion rates have been reported between 3 % and 18 % in the literature [3,5,9–12]. Although previous reports described problems with bleeding due to blunt dissection associated with the transhiatal approach, we experienced no such issues with hemostasis, as our conversions were due to aberrant anatomical considerations. Luketich et al. reported conversion rate of 4.5 % in their large series, with reasons for conversion from laparoscopy most commonly cited as adhesions, inadequate conduit length, tumor bulkiness, or need to better assess margins [13]. Some of the series report early conversions as part of the learning curve.
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