Fig. 13.1
The abdominal port positions are as shown in the figure. The surgeon operates using the right sided ports while the assistant uses the left port
After insertion of the camera port by the open method, pneumoperitoneum is created and an inspection of the liver (Fig. 13.2), peritoneal surfaces and pelvis is carried out to rule out any metastases. The other four ports are placed under vision.
Fig. 13.2
A preliminary inspection of the liver and peritoneal surfaces is done to rule out metastases
13.2.3.2 Mobilisation
Mobilisation is started along greater curvature after visualizing the right gastro-epiploic arcade. The gastrocolic omentum is divided using harmonic shears (Fig. 13.3). We prefer to start the mobilization midway in the gastrocolic omentum (where the omentum is thinnest, enabling the gastroepiploic arcade to be visualized without difficulty) and progress initially towards the fundus and subsequently towards the pylorus.
Fig. 13.3
The gastrocolic omentum is serially divided at a safe distance from the right gastro epiploic arcade taking care to avoid injury to the arcade
After creating a window in the gastrocolic omentum, the mobilization continues towards the fundus, initially dividing the posterior peritoneal reflection over the superior border of the pancreatic body and tail (Fig. 13.4) and subsequently sealing and dividing the posterior short gastric vessels (Fig. 13.5).
Fig. 13.4
The posterior peritoneal reflection is then divided to further free the stomach
Fig. 13.5
The short gastric arteries are carefully sealed and divided, taking extreme care to avoid bleeding
Next, the short gastric vessels from the splenic artery are carefully sealed and divided (Fig. 13.6). The short gastric vessels can cause troublesome bleeding, sometimes necessitating conversion to open surgery and/or splenectomy if not visualized and coagulated well. It is important to be patient while coagulating these vessels and divide them only after complete sealing to prevent this complication, especially when the omentum between the greater curve and the splenic hilum is very short.
Fig. 13.6
The posterior short gastric vessels need to be separately sealed and divided
The mobilization of the stomach on the right should be carried out till the pylorus to ensure adequate length. Care must be taken to avoid injury to the right pastor epiploic pedicle at this level (Fig. 13.7).
Fig. 13.7
The division of the gastrocolic omentum is continued to the right up to the level of the pylorus, preserving the right gastro epiploic pedicle
Care must be taken to identify and preserve the entire right gastroepiploic artery throughout this mobilization to avoid ischemia of the gastric conduit.
The lesser omentum is opened after retracting the liver and serially divided starting from the lesser curvature of the stomach and progressing towards the hiatus (Fig. 13.8). Any accessory/replaced left hepatic arteries arising from the left gastric should be identified and preserved.
Fig. 13.8
The gastrohepatic omentum is divided, taking care to identify and preserve any aberrant hepatic arteries that are occasionally seen
The above maneuver exposes the left gastric vessels which can be identified by lifting the lesser curvature upwards. The left gastric vessels are then dissected (Fig. 13.9) along with the adjacent lymph nodes.
Fig. 13.9
The left gastric vein and artery are dissected, along with the lymph nodes around them
A D2 lymphadenectomy along the hepatic, left gastric, splenic and celiac vessels is completed now (Fig. 13.10).
Fig. 13.10
The hepatic, left gastric and splenic group of lymph nodes are dissected off the named vessels
The left gastric vessels are now ligated (Fig. 13.11) using hemolok clips (our preference) or a vascular stapler and then divided.
Fig. 13.11
The left gastric vein and artery are ligated using clips
The dissection is then carried out posteriorly upto the hiatus; division of the gastrohepatic omentum and phrenoesophageal ligament should not be completed at this stage to avoid the escape of gas and loss of pneumoperitoneum (Fig. 13.12).
Fig. 13.12
The dissection is continued up to the hiatus without opening it to prevent escape of pneumoperitoneum
After ensuring that the entire stomach has been mobilized from the pylorus to the fundus, the hiatal dissection is initiated. The phrenoesophageal ligament and crura are dissected and the gastroesophageal junction is freed from the all the attachment to the retroperitoneum, spleen and crura. This is continued till the thoracic cavity is entered and the lower esophagus is visualized.
13.2.3.3 Creation of Stomach Tube
The stomach tube can be created either intracorporeally or extracorporeally through a small 5 cm minilaparotomy.
When the tube is being created intracorporeally, we start the stapling of the lesser curve at a predefined point (Figs. 13.13 and 13.14), usually at the junction of the left and right gastric artery branches.
Fig. 13.13
The point on the lesser curvature of the stomach where the stomach tube creation is planned is marked
Fig. 13.14
The first stapler is fired to fashion the stomach tube
We progressively form the stomach tube using serial staples, taking care to keep the stomach tube neither too broad nor too narrow (Fig. 13.15). The final staple is not fired from the abdomen to facilitate pulling up of the stomach tube along with the esophagus into the neck wound (Fig. 13.16).
Fig. 13.15
The stomach tube is created by serial firings of the stapler
Fig. 13.16
The stomach tube is formed except for the last firing to maintain the connection between the specimen and the stomach tube
The neck is opened using a transverse incision (see section “Cervical Esophageal Anastomosis”) and the esophagus mobilized.
The esophagus with the stomach tube (connected by the last part of the stomach tube which remains intact) is then pulled through the posterior mediastinum (Fig. 13.17) into the neck wound and the final staple fired to complete the formation of the stomach tube.
Fig. 13.17
The connection between the stomach tube and the specimen permit pulling of the stomach tube along the posterior mediastinum
When the stomach has been adequately mobilized, the pylorus will be seen just below the hiatal opening (Fig. 13.18) facilitating a tension free anastomosis in the neck.
Fig. 13.18
The stomach tube is pulled up along the mediastinum; the pylorus reaches just below the hiatal opening to ensure a tension-free anastomosis at the neck
When the stomach tube is being created extracorporeally, we extend the 5 mm xiphisternal (liver retractor) port incision downward for about 5 cm, introduce a wound protector, and retrieve the full stomach with the mobilized esophagus into the abdomen wound.
The stomach tube is then created extracorporeally using serial stapling (Fig. 13.19), stutured to a tape and pulled into the cervical wound.
Fig. 13.19
Extracorporeal stomach tube creation (all other steps are identical to the intracorporeal stomach tube formation)
The stomach tube is then anastomosed with the proximal esophagus in the neck using a triangulated stapled or a handsewn technique (see section “Cervical Esophageal Anastomosis”).
13.3 Laparoscopic Percutaneous Feeding Jejunostomy
(10)
Department of Thoracic Surgery, Peking University People’s Hospital, No.11, Xizhimen South Street, Beijing, 100044, China
13.3.1 Technical Points
Early initiation of enteral nutrition is preferred over parenteral nutrition for patients undergoing esophagectomy. Laparoscopic percutaneous feeding jejunostomy is a safe and simple technique that adds little to the morbidity and cost of managing patients with esophageal cancers undergone MIE. It facilitates optimization of nutrition in the perioperative period for these patients, especially in those receiving preoperative chemotherapy.
13.3.2 Anatomical Landmarks
Identifying the ligament of Treitz and locating the proximal direction of the bowl are crucial to the technical. A helpful anatomical note is that there is less mesenteric fat in the proximal small bowel compared to the ileum and the presence of “windows” between the mesentery and bowel wall suggests a proximal location.
13.3.3 Operating Procedure
- 1.
The bowel is grasped and run in one direction or the other until the ligament of Treitz is identified. When the ligament of Treitz is identified, a segment of small bowel about 20–30 cm distal is grasped and pushed to the abdominal wall to ensure that the bowel will move that far anteriorly without tension (Fig. 13.20).
Fig. 13.20
A segment of small bowel is grasped and pushed to the abdominal wall to ensure that the free bowel is long enough
- 2.
An appropriate location for the jejunostomy is identified and marked on the antimesenteric surface of the small bowel. The 5 mm trocar incision in the left upper quadrant was chosen as the entry site of the jejunostomy tube on the abdominal wall. Loose Purse-string suture is made with 3-0 MERSILK® around the jejunostomy location (Fig. 13.21).
Fig. 13.21
Loose Purse-string suture is made with 3-0 MERSILK® around the jejunostomy location
- 3.
The silk suture is taken out of the abdominal cavity with a latch needle. So the bowel can be pulled to the abdominal wall (Fig. 13.22a, b).
Fig. 13.22
The silk suture is taken out of the abdominal cavity with a latch needle. The bowel is pulled to the abdominal wall then
- 4.
While retracting the small bowel with the T-Fasteners, an 18 gauge needle is passed through the center of the T-Fasteners into the jejunum. A guidewire is then passed through the needle distally into the jejunum and the needle removed. A split catheter sheath is then passed over the guidewire into the bowel, the guidewire removed, and the jejunostomy tube passed through the split catheter sheath into the jejunum. The split catheter sheath is removed and the T-fasteners are secured to hold the jejunum in place against the abdominal wall (Fig. 13.23).
Fig. 13.23
The process of placing feeding tube
- 5.
A second purse-string suture is sewn with 3-0 MERSILK® at the distal part around the insertion site of the catheter into the jejunum. The silk suture is also taken out with a latch needle as step 3, but through a different puncture point (Figs. 24 and 25).
Fig. 13.24
A second purse-string suture is sewn
Fig. 13.25
The silk suture is taken out with a latch needle
- 6.
The two sutures are pulled tight and tied on the anterior abdominal wall (outside). This maneuver will attach the jejunum against the anterior abdominal wall securely. The suture will be closed at skin level. The jejunostomy tube is fixed using the fixing devices after confirming the tube is not blocked (Fig. 13.26).
Fig. 13.26
The inner sight after the jejunostomy tube is fixed
13.4 Thoracoscopic Esophageal Mobilization
(11)
Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Parel, Mumbai, India
(12)
Department of Thoracic Surgery, Tata Memorial Centre, Parel, Mumbai, India
13.4.1 Technical Points (or Tips)
Thoracoscopic esophageal mobilization is an integral part of the McKeown three phase and the Ivor-Lewis esophagectomy procedures.
The key points to remember are:
Confirm operability before extensive esophageal mobilization to avoid esophageal necrosis in case of inoperability
Avoid injury to the tracheobronchial tree, descending thoracic and arch of aorta
Ligate the thoracic duct if injured, dissected or exposed
The following difficulties may be faced:
Lung collapse may be suboptimal either due to extensive lung adhesions or a smoker’s lung, making dissection difficult.
Meticulous dissection in the regions of the right and left recurrent nerve (RLN) lymph nodal groups is necessary to avoid temporary or permanent RLN paresis/palsy.
Care must be taken to identify and preserve an aberrantsubclavian artery arising from the descending thoracic aorta.
13.4.2 Anatomical Landmarks
Thoracoscopic esophageal mobilization is relatively straightforward as there are very few variations in the anatomical landmarks.
The blood supply of the thoracic esophagus arises primarily from direct branches of the descending thoracic aorta.
The upper half of the esophagus closely abuts the membranous wall of the trachea and the left main bronchus anteriorly.
The pericardium offers a good plane of dissection with the lower half of the esophagus anteriorly.
The horizontal part of the azygous vein with the bronchial artery forms the roof of a tunnel through which the esophagus courses (junction of the upper and middle thirds).
The thoracic duct runs vertically parallel to the vertical part of the azygous vein between it and the descending thoracic aorta, and crosses over to the left side at the level of the tracheal bifurcation.
The right RLN branches out from the right vagus nerve just after it crosses the right subclavian artery; the left RLN has a much longer course and is given off from the left vagus just after it crosses the aortic arch, and runs along the left tracheo esophageal groove
13.4.3 Operating Procedure
13.4.3.1 Ports, Pneumothorax, Instruments
We place the patient on the right edge of the operating table, in the left lateral position, with the operating surgeon standing posterior to the patient and the assistant standing anterior. Monitors are placed both anterior and posterior to the patient to facilitate good visualization for both the surgeon and the assistant.
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