Minimally Invasive Esophagectomy





Surgical Anatomy





  • The esophagus includes cervical, thoracic, and abdominal segments and travels through the posterior mediastinum to join the stomach via the esophageal hiatus of the diaphragm. It is accompanied along its course by the anterior and posterior vagal trunks.



  • The esophagus is a muscular tube, approximately 25 cm long and lacks a serosal layer. It is lined with squamous epithelium and transitions from striated muscle to smooth muscle as it courses through the thoracic cavity. The blood supply of the esophagus is segmental with limited overlap. The lymphatic anatomy is rich in intramural, extramural, and transmural channels, thus allowing for the rapid spread of an early localized tumor to metastatic disease.



  • Surgical resection remains the primary treatment modality for resectable esophageal cancer, and transhiatal esophagectomy and Ivor Lewis esophagogastrectomy are the two most commonly performed operations.




    • A transhiatal esophagectomy is performed through a midline abdominal incision with blunt dissection of the thoracic esophagus through the esophageal hiatus, a gastric pull-up, and a cervical esophagogastric anastomosis.



    • An Ivor Lewis esophagectomy is performed through an upper midline abdominal incision with mobilization and creation of the gastric conduit followed by a right thoracotomy with dissection and removal of the thoracic esophagus and construction of an intrathoracic esophagogastric anastomosis.



    • Both transhiatal and Ivor Lewis esophagectomy are complex operations that have considerable morbidity and mortality in the range of 6% to 7% in experienced centers. However, in a national review, the mortality rate from esophagectomy ranges from 8% in high-volume centers to as high as 23% in low-volume centers.




  • Laparoscopy has become the standard approach in the treatment of a variety of benign esophageal diseases, such as reflux and achalasia. This shift has been driven by a consistent observation that minimally invasive surgery is associated with equal efficacy, less pain, and an earlier return to work compared with open surgery. However, an open approach is still the standard of care for patients with esophageal cancer because of concerns that (1) minimally invasive surgery may not be equivalent in terms of nodal clearance and completeness of resection, (2) a minimally invasive approach may not have a measurable impact on morbidity, and (3) most esophageal surgeons have not been trained to perform the procedure minimally invasively.



  • Data to support the claim that minimally invasive esophagectomy (MIE) is associated with less morbidity and mortality than the open approach exist and continue to accumulate. Two of the more frequent complications following esophagectomy are pneumonia (which carries a 20% mortality risk) and pulmonary failure. The avoidance of synchronous laparotomy and thoracotomy incisions may reduce the incidence of these complications. Although no randomized studies have been performed, our experience and that of others has suggested that MIE is associated with a lower rate of complications and mortality than that following open esophagectomy.






Preoperative Considerations





  • The preoperative evaluation for a patient undergoing an MIE is no different from that for a patient undergoing an open procedure.



  • The two primary issues are whether the esophageal tumor is resectable and whether the patient has sufficient cardiopulmonary reserve.



  • Staging of esophageal cancer includes an upper endoscopy, endoscopic ultrasound (EUS), computed tomography (CT) scanning, and positron emission tomography (PET) scanning. Upper endoscopy is performed to identify the proximal and distal extent of the tumor, which may impact the type of procedure performed; this is often done in the operating room at the time of the operation.



  • The primary benefit of EUS is to determine the degree of invasion of the esophageal wall. Patients with T3 or N1 disease are usually treated with induction chemotherapy before esophagectomy. CT imaging is useful to determine the presence of bulky nodal disease within the abdomen. Bulky disease limited to the celiac nodal basin does not preclude esophagectomy, provided there is significant response to induction therapy. Finally, PET scanning, along with CT imaging, is primarily used to assess distant metastatic disease, which would preclude esophagectomy. We have not found PET particularly helpful in identifying periesophageal nodal disease because activity within these nodes is often obscured by the primary tumor.



  • A final staging modality is laparoscopy. Typically patients undergo laparoscopy at the time of placement of an infusaport for induction chemotherapy. We have found laparoscopy to be a simple and safe method to identify abdominal metastases (liver or peritoneal) that might not be seen on CT imaging. In addition, the presence of bulky nodal disease can be assessed by laparoscopy and confirmed by biopsy. For these patients, additional radiation therapy may be included to the neoadjuvant treatment plan. Laparoscopy usually can be completed within 30 minutes, and patients can be discharged home on the same day.



  • Patients should undergo a thorough evaluation to determine medical suitability for operation. This includes a cardiac stress test and, if indicated, coronary angiography. Patients with a significant tobacco history also should undergo pulmonary function testing. In addition, most patients with locally advanced cancer will have some degree of dysphagia and weight loss before diagnosis. Dysphagia often improves with induction therapy. If the patient has severe dysphagia, we place a jejunostomy tube during laparoscopic staging, although this has not been common for us. We strongly discourage the placement of either an esophageal stent or percutaneous gastrostomy tube for any patient who might be an operative candidate. Although esophagectomy is still possible in these situations, it is technically more challenging.






Operative Steps





  • Our early technique consisted of thoracoscopic esophageal mobilization followed by laparoscopic construction of the gastric conduit, gastric pull-up, and a neck anastomosis. A minimally invasive Ivor Lewis technique was reported by Watson and colleagues in 1999, who described the laparoscopic construction of a gastric conduit followed by thoracoscopic esophagectomy with construction of an intrathoracic esophagogastric anastomosis.



  • The benefit of the minimally invasive Ivor Lewis approach is that it avoids a neck incision, therefore lowering the likelihood of a recurrent laryngeal nerve injury. There is also an absence of anastomotic tension, improved conduit perfusion, and a subsequent decrease in dehiscence rate. Initially, the operation was a hybrid, encompassing laparoscopy with a right mini thoracotomy. As our experience grew, we began to perform the operation completely minimally invasively. We have performed close to 250 minimally invasive Ivor Lewis esophagectomies. The operative details are similar to the three-hole approach, but we start the operation with laparoscopic construction of the gastric conduit followed by right video-assisted thoracoscopic surgery.




Abdominal Dissection





  • The patient is positioned supine and intubated with a double-lumen endotracheal tube. On-table endoscopy is performed to assess tumor location and extension. The suitability of the stomach as a gastric conduit is also evaluated. Care must be taken to avoid undue insufflation during endoscopy.



  • Proceeding with laparoscopy, the surgeon remains on the right while the assistant is positioned to the patient’s left side.



  • Six abdominal ports are used for the gastric mobilization ( Fig. 27-1 ). The initial port is placed via an open technique while the remaining ports are placed under direct visualization. After an initial inspection of the peritoneal surfaces and the liver to rule out metastatic disease, the gastrohepatic omentum is opened.




    Figure 27-1



  • The left gastric pedicle is identified, and the celiac nodes are examined. If there are any enlarged nodes suspicious for metastatic implants, they are dissected and sent for frozen section analysis. If the nodes are not worrisome or return negative, the right crus is dissected free, mobilizing the lateral aspect of the esophagus.



  • The dissection is then carried anteriorly and superiorly, mobilizing the anterior hiatus. Continuing this dissection toward the left crus, the fundus of the stomach begins to be mobilized. Avoid complete division of the phrenoesophageal ligament until conclusion of laparoscopy to maintain optimal pneumoperitoneum.



  • After creating a retroesophageal window by completing the dissection of the inferior aspect of the right crus, attention is turned to the gastrocolic omentum. By carefully retracting the antrum of the stomach, a window is created in the greater omentum, allowing access to the lesser sac. This is done while carefully preserving the right gastroepiploic vessels.



  • The dissection is carried along the greater curve of the stomach until the end of the gastroepiploic arcade is reached. The short gastric vessels are taken with a combination of the ultrasonic shears (Harmonic Scalpel, Ethicon Endo-Surgery Inc, Somerville, NJ) or the LigaSure device (Covidien, Mansfield, MA). Occasionally, clips are used to control large-diameter, short gastric vessels. With the greater curve mobilized, the fundus of the stomach is rotated toward the liver, exposing the retrogastric attachments. These are dissected free until the left gastric artery and vein are encountered. The retrogastric attachments are also divided toward the hiatus, completely mobilizing the fundus and the distal esophagus. The mobilization of the stomach is then carried back towards the pyloroantral region, where the dissection must be meticulous.



  • An injury to the gastroepiploic arcade or the gastroduodenal artery renders the gastric conduit unusable. There are significant retroantral and periduodenal adhesions that must be divided to allow for adequate mobilization of the stomach. Since we have transitioned to an intrathoracic anastomosis, we have noted that an extensive Kocher maneuver is not necessary. The pylorus is considered adequately mobilized when it can reach the right crus under no tension.



  • Once the stomach is completely mobilized, the left gastric artery and vein are divided with a vascular load on the EndoGIA stapler (Ethicon Endo-Surgery Inc, Somerville, NJ). This is done by approaching the pedicle from the lesser curve. It is important that the pedicle be dissected completely, with all celiac nodes swept up onto the specimen ( Fig. 27-2 ). Once the pedicle is divided, the distal esophagus and the gastric fundus and antrum are completely mobilized.


Mar 13, 2019 | Posted by in CARDIOLOGY | Comments Off on Minimally Invasive Esophagectomy
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