First described in ad 160 by Galen, the esophagus has proved to be a challenging organ to understand and manipulate. Its complex physiology and treacherous location in the posterior mediastinum precluded surgical manipulation until the 20th century. The first thoracic esophageal resection was described by Torek in 1915.¹ He illustrated a resection of the midesophagus with an extra-anatomic reconstruction. Although he described only one survivor, this event heralded the beginning of esophageal surgery. For the remainder of this century and into the next, surgeons have endeavored to improve the technique and outcomes of this thoracic specialty.

Orringer and Sloan² popularized a transhiatal approach to esophageal resection and a gastric tube reconstruction. McKeown³ described a three-field approach requiring a thoracotomy to perform the majority of the esophageal dissection, followed by a laparotomy for the gastric mobilization, and finally, a cervical incision for anastomosis. Variations in approaches and reconstructions have provided today’s surgeons with a large armament of techniques and fodder for debate over the ideal approach.

Open surgical procedures remain the standard of care for esophageal resections in most medical centers. However, the morbidity and mortality associated with open procedures and the diseases for which they are required still reveal the need for further improvement. A 10-year review of the esophagectomy experience within the Veterans’ Affairs hospital system revealed a morbidity of 50% and a mortality of 10%.⁴ Birkmeyer et al.,⁵ in a recent analysis of a national Medicare database, revealed that the mortality rates from esophagectomy in the United States ranged from 8% in high-volume centers to 23% in low-volume centers.

The advent of laparoscopy and thoracoscopy in the 1980s opened the door to the possibility of a minimally invasive approach to esophageal surgery. Initial experience with laparoscopic Nissen fundoplications formed the basis of the early surgical experience, followed by the use of laparoscopic and thoracoscopic staging of lymph nodes. Collard et al.⁶ were the first to describe a thoracoscopic technique for esophageal dissection. Although multiple reports of laparoscopic-assisted esophagectomies followed, it was not until DePaula et al. published their initial experience in 1996 that a totally laparoscopic esophagectomy was documented.⁷ Although this report detailed a laparoscopic transhiatal approach,^8–10 our center and others have used primarily a combined thoracoscopic and laparoscopic approach.^11–14 The thoracoscopic approach affords better visualization of the periesophageal structures, especially near the main airways and subcarinal areas. It is also less affected by patient height and body habitus and, in our experience, improves nodal dissection and overall visualization compared with the totally laparoscopic method. In 2000, Nguyen et al.¹⁵ compared the minimally invasive approach with open transthoracic and transhiatal esophagectomy. The minimally invasive approach documented shorter operative times, less blood loss, and shorter stays in the intensive care unit with no increase in morbidity compared with the open approach.

Indications

Indications for the minimally invasive approach for esophagectomy include Barrett esophagus with high-grade dysplasia, end-stage achalasia, esophageal strictures, and esophageal cancer.^16–20 While most T4 esophageal cancers generally are not amenable to any surgical approach, all other T stages should be amenable to minimally invasive esophagectomy (MIE) in experienced hands. Downstaged cancer with neoadjuvant chemoradiation is also resectable by a minimally invasive approach. Previous thoracic and abdominal surgery is not necessarily a contraindication depending on the extent of the previous surgery and the experience of the surgeon performing the esophagectomy.

Operative approaches to MIE have varied from a 3-hole modified McKeown to the Ivor Lewis approach. While our initial experience was largely the 3-hole approach with the initial dissection starting in the chest, over the past several years we have favored the Ivor Lewis approach.²¹ A high thoracic anastomosis can be performed thoracoscopically approaching the same level as a neck dissection. In addition, avoidance of a neck dissection minimizes recurrent nerve injury, dysphagia, and aspiration. Furthermore, the anastomosis is generally performed at a level on the gastric conduit that is better perfused by blood and hence is less likely to be damaged by ischemia. Below we describe the minimally invasive Ivor Lewis approach but modifications for the 3-hole approach are also discussed.

Technique

Positioning

Esophagogastroscopy is performed in all patients to confirm the location of the tumor and the suitability of the stomach for tubularization. For midesophageal tumors, a bronchoscopy is also indicated. The patient is intubated with a double-lumen endotracheal tube at the start of the case. Both lungs are ventilated during the abdominal dissection. The right lung is isolated during the thoracic dissection to provide adequate visualization and mobilization of the esophagus.

Laparoscopy

The patient is placed supine. Five ports are used for the gastric mobilization (Fig. 15-1). A 10-mm port is placed right of midline in the epigastrium, slightly below the midpoint between the xiphoid process and the umbilicus. The port is inserted under direct vision. The patient is placed in a steep reverse Trendelenburg position. A 5-mm port is placed to the left of midline at the same level as the original port. A 5-mm, 30-degree camera is placed through this port. Additional 5-mm ports are placed at the left subcostal margin and the right subcostal margin. A 5-mm port is placed in the right flank to support a liver retractor. A self-retaining retractor is used to elevate the left lobe of the liver and expose the hiatus (Fig. 15-2). The gastrohepatic ligament is divided to expose the right crus. The esophagogastric junction is freed from the hiatus by dissection up the right crus. The phrenoesophageal ligament is taken down, and the dissection is extended to the left crus. The right gastroepiploic arcade is identified, and the gastrocolic ligament is divided lateral to this arcade. Dissection is carried up along the greater curvature of the stomach, taking down the short gastric arteries. Once dissection is carried up toward the left crus, the posterior attachments of the gastroesophageal junction can be divided. The stomach is retracted superiorly and to the right to expose the celiac vessels. Celiac and gastric nodal tissue is dissected free and left with the specimen. The left gastric artery then is isolated and divided at the base using an Endo-GIA vascular stapler (Covidien, Norwalk, CT). The stomach itself must be handled with care at all times to minimize traumatic injuries to the tissue.

A Kocher maneuver is performed, and the retrogastric and duodenal attachments are carefully dissected to achieve adequate mobilization of the gastric tube. Adequate mobilization should permit the pylorus to reach the right crus with ease. This should be reassessed at several time points during the mobilization to inform the surgeon of the degree of dissection required. If there is any difficulty with this maneuver, further pyloroantral mobilization generally is required.

The gastric tube construction is now initiated by firing the Endo-GIA stapler across the lesser-curve vessels and fat at an angle pointing toward the incisura. For the first firing, we generally use a vascular load (white) with a staple height of 2.5 mm to minimize small-vessel oozing along the lesser curve (Fig. 15-3A). The right gastric vessels are preserved. The angle of the first few staple firings will determine the gastric tube diameter, and the staples should be placed accordingly. We prefer to create a gastric tube that is approximately 4 to 5 cm wide. In addition, we apply slight caudal and simultaneous cephalad traction during application of the stapler to keep the gastric tube on slight stretch (Fig. 15-3B). This will afford better length of the final tube. Subsequent firings of the stapler should be maintained in a line parallel to the greater-curvature arcade to create a consistent tube width and avoid spiraling of the tubularized gastric conduit. The staple load used along the thick gastric antrum may require the green stapling cartridge (4.8-mm height). As the stapling continues toward the fundus, we generally use the blue loads (3.5-mm height). The staple line is inspected for hemostasis. The conduit is observed while the pyloroplasty is completed. A pyloroplasty is performed in Heinecke-Mikulicz fashion (see Chapter 17). An Endo Stitch (Covidien, Norwalk, CT USA) is placed superiorly and inferiorly on the pylorus to provide retraction. Ultrasonic shears are used to incise the pylorus, and the opening is closed transversely using 2-0 interrupted endosutures. The resected specimen is attached to the gastric tube with two endosutures (Fig. 15-4). These sutures should be placed from the tip of the fundic portion of the tube to the lesser-curve portion of the resected specimen. This technique tends to minimize the bulk as the specimen and gastric tube are passed through the hiatus (Fig. 15-5).

An additional 10-mm port is placed in the right lower quadrant to facilitate jejunostomy tube placement. The transverse colon is retracted cephalad using a grasper applied to the adjacent fatty epiploicae, and the ligament of Treitz is identified. Approximately 40 cm from the ligament of Treitz, a loop of jejunum is attached to the anterior abdominal wall in the left lower quadrant using an Endo Stitch. A 10-Fr laparoscopic feeding jejunostomy tube is inserted into the jejunum percutaneously using the Seldinger technique. The guidewire is threaded into the small bowel, followed by the catheter, to a distance of approximately 20 cm. The jejunum is further tacked to the anterior abdominal wall using three additional endosutures as well as a single suture approximately 3 cm distal to the entrance site to prevent torsion. The feeding catheter is secured on the skin, and 10 mL of air is injected rapidly into the small bowel to test for patency and confirm intraluminal placement. If any doubts exist as to true luminal placement, an on-the-table Gastrografin study of the jejunostomy tube should be performed.

Thoracoscopy

The patient is placed in the left lateral decubitus position. The right lung is isolated. Four ports are used to access the right chest (Fig. 15-6). A 10-mm camera port is inserted in the anterior axillary line at the eighth interspace. An additional 10-mm port is placed approximately 2 cm posterior to the posterior axillary line in the eighth or ninth interspace. This is the main dissection port for the harmonic scalpel (Ethicon). A 10-mm port is placed in the fourth interspace along the anterior axillary line. A fan retractor is placed through this port to provide retraction of the lung. Finally, a 5-mm port is placed below the scapular tip. A fifth 5-mm port can be placed at the sixth rib, at the anterior axillary line, for suction by the assistant. The addition of insufflation can depress the diaphragm to give better visualization of the hiatus. Alternatively, an Endo Stitch can be placed in the central tendon of the right diaphragm and brought out percutaneously through the lower chest wall near the costal margin using the Endo-Close device (Covidien, Norwalk, CT). Downward traction on this stitch pulls the diaphragm inferiorly and allows better visualization of the lower esophagus and hiatus.

Dissection is begun by taking down the inferior pulmonary ligament (Fig. 15-7). The mediastinal pleura is dissected anteriorly along the plane between the edge of the lung and the esophagus and is resected with the specimen up to the azygos vein. The subcarinal lymph nodes are taken en bloc with the esophagus. Care is exercised to avoid injury to the posterior membrane of the right mainstem bronchus, carina, and trachea. Dissection is carried up to the azygos vein, and the vein is divided with an Endo-GIA stapler (Covidien, Norwalk, CT).