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Thoracoscopic and laparoscopic esophagectomy
INTRODUCTION
Minimally invasive esophagectomy (MIE) has become an established option in the approach to esophageal resection and reconstruction for cancer. Technical and oncological outcomes are similar to those of open surgery, with evidence for improved respiratory outcomes with the MIE approach. The resection may be performed as a total MIE or there may be a combination of open and minimally invasive approaches (hybrid). The approach is used for cancers of the esophagus and gastroesophageal junction (GEJ). In our unit, the decision with respect to approach relates to the site of the primary cancer. The three-field dissection is suitable for cancers restricted to the esophagus. The two-field, Ivor Lewis, approach is used for cancers of the mid/lower and GEJ where there is gastric involvement that requires a proximal gastric resection that will not leave enough stomach for a neck anastomosis. The open approaches to the thoracic esophagus, including mobilization of the stomach to construct the gastric conduit, are described elsewhere (see Chapter 32, “Abdominal and right thoracic esophagectomy” and Chapter 33, “Left thoracic subtotal esophagectomy”).
The laparoscopic gastric mobilization can be performed as the first phase of an Ivor Lewis approach with the chest performed open or thoracoscopically. It can be performed as the second phase of a three-field resection when the thoracoscopic component is the first phase and a cervical anastomosis is performed. Initially, we will describe laparoscopic gastric mobilization as the first phase of an Ivor Lewis resection, and then, as part of a three-phase thoracoscopic esophageal mobilization with a gastric conduit taken to the neck. Then we will describe the prone thoracoscopic approach used for a three-phase procedure and finally the thoracoscopic approach for an Ivor Lewis procedure with an intrathoracic anastomosis.
Patients have a double lumen endotracheal tube inserted to allow single-left lung ventilation, although a single lumen endotracheal tube may be used with carbon dioxide (CO2) pneumothorax, with the insufflation pressures set at 7 mmHg.
LAPAROSCOPIC GASTRIC MOBILIZATION (SEE FIGURE 35.1)
The patient is positioned in the reverse Trendelenburg position, with the table tilted 20-30 degrees head up. The legs are extended in stirrups with minimal hip flexion. The surgeon stands between the legs and there is an assistant who holds the camera standing on the patient’s left. The video monitor is to the left of the head of the table at the level of the patient’s shoulder.
35.1
35.2
Trocar placement (see Figure 35.2)
The initial port is either a 12 mm Hasson cannula placed by a cut down or an optical port placement in the midclavicular line between the umbilicus and the left costal margin. The abdomen is insufflated to a pressure of 12 mmHg. Following the insertion of a 30-degree laparoscope, a 12 mm port is inserted above the umbilicus (B). Two 5 mm ports are placed in the right upper quadrant (C), the left lateral abdomen (D), and a 5 mm incision is made in the epigastrium to place a Nathanson liver retractor (Cook Group Incorporated, Bloomington, Indiana, United States). If the gastric tube is to be fashioned intracorporeally, then the right upper quadrant port (C) should be 12 mm, rather than 5 mm. The dotted line on Figure 35.2 is the site of an incision if the plan is to create a gastric tube extracorporeally. The supra-umbilical port incision is extended as a midline incision, measuring 6 cm.
Mobilization of the greater curve of the stomach
The gastroepiploic arcade is identified and carefully preserved. Omental branches are divided with either the Harmonic scalpel (Ethicon, U.S., LLC, Somerville, New Jersey, United States) or LigaSure (Covidien, Medtronic, Dublin, Ireland, and Fridley, Minnesota, United States) to identify and enter the lesser sac. Visualizing the gastroepiploic arcade, the dissection is taken proximally, maintaining the arcade. Short gastric branches are taken, leaving a minimum of a 3 cm cuff of omentum to ensure collateral vessels to the fundus are preserved. We also prefer to leave sufficient omentum to wrap the anastomosis if it is to be performed in the chest. The gastric fundus is mobilized to the right, identifying the left crus of the diaphragm. A cuff of crural muscle is taken if the cancer is in the lower esophagus or GEJ. This dissection also clears the tissue above the pancreas toward the left side of the left gastric artery.
Now the dissection is taken distally. The right gastroepiploic origin will become obvious along the inferior margin of the pancreas. Omental branches are divided to allow the duodenum to become mobile. The posterior stomach is mobilized and the posterior pylorus mobilized to the gastroduodenal artery. Adhesions around the duodenum are divided to ensure that the pylorus will mobilize to the hiatus.
Dissection of the hiatus and division of the left gastric vascular pedicle
The gastro-hepatic ligament is divided and the right crus of the diaphragm incised, leaving crural muscle and pleura on the esophagus if a lower or GEJ cancer. The dissection is carried anteriorly to dissect the fat pad from the pericardium.
Now attention returns to the posterior stomach and the left gastric pedicle is defined. The nodal tissue over the common hepatic artery (station 8a) is mobilized from the artery with the Harmonic shears (Ethicon, U.S., LLC). This is dissected toward the vascular pedicle to define the left gastric vein, which is divided between clips. The nodal tissue is dissected proximally (station 9), and the left gastric artery is defined. It is dissected clear on the left side. The nodal tissue above the proximal splenic artery (station 11) is dissected to expose the left side of the left gastric artery. This is divided between clips or by using a laparoscopic stapling device. A pyloromyotomy can be performed if considered necessary.
The dissection returns to the hiatus and is carried proximally into the mediastinum. If required, the pleura on one or both sides can be removed. The anesthetist should be informed that the pleura has been breached, as tension pneumothorax can occur when there is only a small hole made in the pleura (due to flap valve formation), prior to more formal pleural resection. The dissection will meet a prior thoracoscopic dissection if a three-phase procedure, or alternatively, if this is the first phase of a two-phase dissection, the dissection is taken as high as possible around the esophagus under direct vision. An intercostal catheter with underwater sealed drainage may be necessary if the pleura on the left side is resected. Tube drainage of the left chest is often not necessary and the use of left chest drainage can be guided by surgeon preference.
Gastric conduit construction as phase one of two-phase procedure (Ivor Lewis) (see Figure 35.3)
The lesser curve is cleared by the shears above the level of the vascular “crow’s foot” and the stomach is divided by endostaplers, aiming for a 4-5 cm margin distal to the cancer. At this stage, the gastric conduit can be formed totally intracorporeally or via a small midline laparotomy abdominal incision (see Figure 35.2 ). If intracorporeal, the division is taken toward the greater curve but not completed to allow the stomach to be pulled into the mediastinum. The gastric tube should be at least 6 cm in diameter. Care should be taken to preserve all attached omentum so that it may be used later to wrap around the anastomosis in the chest. A feeding jejunostomy can be constructed laparoscopically or via a small 3-4 cm incision having identified the appropriate jejunal segment laparoscopically.
If the conduit is formed via a midline minilaparotomy, a 5-6 cm incision is extended from the supra-umbilical port (see Figure 35.2 ). This minilaparotomy is used to fashion the feeding jejunostomy. A nylon tape (or equivalent) should then be sutured to the proximal end of the gastric conduit (fundus) with a heavy suture (such as 0 Monocril). The conduit is then placed back into the abdomen, paying careful attention to maintain normal anatomical lie of the stomach. The nylon tape is then placed high into the right chest through the hiatus for retrieval during the thoracoscopic chest phase.
The feeding jejunostomy is then formed and secured to the abdominal wall, and the incision is closed.
Gastric mobilization as phase II of a thoracoscopic, laparoscopic mobilization with cervical anastomosis (see Figure 35.4)
If the patient is having a three-field resection, the esophagus will have been divided in the neck and a tape will have been attached. The esophagus is pulled into the abdomen with the attached tape. A small epigastric incision is made above the umbilicus (see Figure 35.2—dotted line) and a retraction device is placed to retract and to protect the wound. The stomach and esophagus are delivered to construct the gastric tube. The gastric tube is constructed by dividing the tissue on the lesser curve above the crow’s foot region. The stomach is extended and divided with a linear stapling device, allowing a suitable margin from the tumor if lower esophagus, and a tube 5-6 cm wide is constructed with multiple staple applications. The staple line is inverted with sutures. Bulky omental attachments are reduced, ensuring vascularity to the fundus. The tape from the neck is attached to the apex of the fundus and the gastric tube returned to the abdomen. A feeding jejunostomy can be performed at this stage through the small laparotomy wound. The abdominal wound is closed and the abdomen is inflated once more.
The gastric tube is gently fed into the hiatus while traction is placed on the tape at the neck. It is advisable to extend the crural dissection if difficulties are encountered feeding the stomach and omental attachments through the hiatus. Care is taken to ensure the gastric tube is not twisted. The gastric tube is delivered to the neck, ensuring the pylorus is just below the level of the hiatus. The cervical anastomosis is performed (see Chapter 29, “Esophageal anastomoses: sutured and stapled”).
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35.4
THORACOSCOPIC ESOPHAGEAL MOBILIZATION (PRONE POSITION) FOR THREE-FIELD DISSECTION
Positioning (see Figure 35.5)
The patient is positioned prone with both arms placed forward on padded arm supports. The patient’s head is placed in a Mayfield headrest, two pillows placed under the shoulders and the hips with the abdomen free between. Further pillows are placed under the knees and legs to prevent any pressure areas. The surgeon stands on the patient’s right side with the assistant standing on the surgeon’s left-hand side. The monitor and stack are placed on the patient’s left-hand side, opposite the surgeon.
Trocar placement (see Figure 35.6a and b)
A 10 mm 30-degree camera port is placed at the inferior border of the angle of the scapula. Blunt dissection is used to enter the thoracic cavity once lung deflation has been achieved via the double lumen endotracheal tube. A 10 mm port is then placed at approximately the level of the azygos arch, medial to the border of the scapula. This is the main working port for the surgeon. A 10 mm port is then placed in the 9th or 10th intercostal space, near the post axillary line, sliding over the dome of the diaphragm—this will be the surgeon’s left-hand working port and enables a stapling device to be deployed to divide the azygos arch. A further 5 mm port can be placed inferior to the superior 10 mm port to allow the assistant to retract or suction if required.
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