Fig. 14.1
Supine position with elevation of pelvic region, umbilical incision as observation port for laparoscope, incisions at the lateral border of the rectus abdominis muscle and both costal margin in midclavicular line as operation port
Patients are positioned on their left side for the thoracic portion of the operation, with a 1.5 cm incision at the anterior axillary line of the seventh intercostal space and the lower corner line of shoulder, and a 4–5 cm lesion at the anterior axillary line of the fourth intercostal space (Fig. 14.2)
Fig. 14.2
Lateral recumbent position of thoracic operation, 1.5 cm incision at the anterior axillary line of the 7th intercostal space and the lower corner line of shoulder, and a 4–5 cm lesion at the anterior axillary line of the fourth intercostal space
Tips
There is no need to extend the previous operation window, nor add an additional incision, with only three conventional incisions required. The operation window is located at the anterior axillary line of the fourth intercostal space, which allows for dissociation of the diaphragm defect and suture fixation, as well as completion of the anastomosis at the proximal end of the esophagus and intrathoracic portion of the stomach.
14.1.3 Operation Procedure
Abdomen (description)
- 1.
After achieving pneumoperitoneum and introducing a 30° thoracoscope, dissect the gastroepiploicasinistra, short gastric vessels, right and left gastric arteries with the surrounding fat, and lymph nodes using a LigaSure (our preference) or ultrasonic scalpel, while maintaining the right gastroepiploic artery. Simultaneously complete the lymphadenectomy.
- 1.
Tips
The left gastric vessels can be ligated with a Hemo-lock or a 30 mm linear-cutting stitching instrument.
- 2.
Dissect the stomach distal to the gastric antrum and proximal to the diaphragm, as well as the abdominal esophagus, and divide the diaphragmatic crura in order to expand the hiatus. Irrigate the abdominal cavity and place abdominal drainage tubes around the gastric wall; close the incision.
Tips
It is not necessary to make a separate incision to prepare the gastric tube, which is usually under the xiphoid process. We are more accustomed to preparing the gastric tube posteriorly, in the intrathoracic cavity.
Key point: Divide the crura of the diaphragm as much as possible in the abdominal cavity, dissect the abdominal esophagus, and thus position the stomach in the thoracic cavity more conveniently.
Chest
Dissect the esophagus in the left lateral position and make the intrathoracic anastomosis. Make a 1.5 cm small incision at the seventh intercostal space in the anterior axillary line, with the bottom angle of the shoulder as the observation port and the auxiliary operative port, and another 4–5 cm small incision at the anterior axillary line of the fourth intercostal space as the main operating port.
Use an electronic hook to divide the right inferior pulmonary ligamentand the mediastinal pleura along the posterior margin of the inferior pulmonary vein to the azygos venous arch. Dissect the seventh, nineth, and tenth lymph node groups. Dissect and ligate the azygos venous arch with a 30*2.5 Endo-GIA. Continue to separate the anterior esophagus and dissect the upper mediastinal periesophageal lymph nodes, taking care to protect the recurrent laryngeal nerve.
Dissect and completely separate the mediastinal pleura on the posterior wall of the esophagus along the anterior margin of the vertebral column. Pay attention to deal with the esophageal artery branches (we usually utilize electrocoagulation and titanium clips to ligate esophageal artery branches) during the lymphadenectomy.
Separate the entire esophagus circumferentially beneath the tumor (separate the esophagus above the tumor in carcinoma of the gastric cardia or near the gastroesophageal junction). Place and pull variceal bands to dissect the left side of the esophagus and tumor site, anteriorly to the anastomosis site. In the case of obvious tumor invasion, careful separation is required, with caution so as not to damage the azygos vein and intrathoracic duct.
Finally, fully dissect the esophagus beneath the tumor to the diaphragm. Completely relax the esophagus beneath the tumor and around the cardia with a 3–4 cm lateral incision made along the hiatus. Ensure that the stomach can be brought up to the thoracic cavity.
Approximately 5 cm above the tumor, using an endoscopic needle with a 2-0 silk suture, perform an esophageal purse-string suture with four to five stitches in total (Fig. 14.3).
Fig. 14.3
Approximately 5 cm above the tumor, using an endoscopic needle with a 2-0 silk suture, perform an esophageal purse-string suture with 4–5 stitches in total (a–c)
Tips
Theoretically, a manual purse suture is difficult to perform; however, intraoperatively, the direction and angle of the dissected esophagus can be adjusted freely and is suitable for suturing. Especially with the posterior wall stitch, the suture line can be continued circumferentially to the front, and sutured counterclockwise around the esophagus. A traditional purse string forceps has a wide front plier head, which makes suturing and line packaging from the same incision different, considering the space limitations during intrathoracic anastomosis. As the operative window is already occupied by the purse string forceps, an additional incision is required to complete the suture. For surgeons experienced with laparoscopic suturing, an esophageal purse string suture is easy to perform.
At the bottom of the purse-string suture, electrocoagulation is used to open the entireone-third to one-half of the esophagus to expose the esophageal lumen (Fig. 14.4). Under endoscopy, the anesthesiologist slowly withdraws the gastric tube to 1 cm above the esophageal anastomosis, which is fully exposed to allow for examination of the condition of the esophageal mucosa. The stapler nail anvil needle holding forceps (patent product, ZL 2014 3 0122322.4; ZL 2014 2 0234093.X; PCT/CN/2014/088998) is then used to staple and the anvil is placed inside the proximal esophagus through the esophageal incision (Fig. 14.5), tightening and closing the purse-string suture (Fig. 14.6).
Fig. 14.4
Electrocoagulation is used to open one-half of the esophagus to expose the esophageal lumen at the bottom of the purse-string suture
Fig. 14.5
The stapler nail anvil needle holding forceps (patent product, ZL 2014 3 0122322.4; ZL 2014 2 0234093. X; PCT/CN/2014/088998) is used to staple and the anvil is placed inside the proximal esophagus through the esophageal incision
Fig. 14.6
Tightening and closing the purse-string suture
Tips
The esophageal stapler anvil needle holding forceps (our independently patented product) can stably clamp the holding stapler anvil and easily feed the nail anvil into the pre-sutured purse suture due to its inclined angle.
A more important role of the holding forceps is that, during subsequent docking of the nail anvil and anastomotic rods, it can stably fix the nail anvil, allowing for accurate and easy docking of the nail anvil and anastomotic rods. This invention has significantly improved the performance of the anastomosis, which due to lack of specialized instrument, and intrathoracic anastomosis position, as well as the unfavorable operational angle between the operative port and auxiliary operativeport, avoiding secondary injury of the esophagus, stomach, and other organs in the intrathoracic cavity previously.
Use an electrocoagulation hook to divide the esophagus and close the end of the esophagus. Use two oval forceps from the main operative port and auxiliary operating port, to bring the stomach from the abdominal to the thoracic cavity. Extract the esophagus from the main operating port and close the cardia with a Kocker clamp. Using a linear line cutting stapler along the distal end of the Kocker clamp, create the gastric tube; arotary nail box can be used based on the angle (Fig. 14.7a).
Fig. 14.7
Using a 3.5 mm thickness of linear line cutting stapler create the gastric tube; arotary nail box can be used based on the angle, a nail box of 2.5 mm thickness is used at the distal part of the omentum (a, b)
Tips
Preparation of the gastric tube: extract the divided esophagus and gastric fundus, which has been closed by a Kocker clamp. With the space for the anastomosis reserved, use a linear stapler to divide the stomach along the lesser curvature, beneath the cardia.
In the process of bringing the stomach up from the abdominal to the thoracic cavity, the oval forceps in the main port should retain the edge of the lesser curvature of stomach. Even though damage might occur, this damaged portion can be resected in the process of creating thegastric tube. The oval forceps in the assisting port should be used to gently retract the body of the stomach, while avoiding damage to the right gastroepiploic artery and gastric wall.
In addition, use a nail box of 2.5 mm thickness at the distal part of the omentum, close to the right gastric artery to prevent bleeding, due to insufficient closure of the right gastric artery (Fig. 14.7b). Examine the cutting edge to decide whether an embedding suture is needed.
After the completion of the gastric tube, open the clamp and release the open end. After aspiration of the gastric contents, a traction line was sewn at the 3 o’clock, 6 o’clock, and 12 o’clock positions; introduce the tube into the intrathoracic cavity. Place a long tissue clamp into the intrathoracic cavity from the scapular line incision, maintaining the 9 o’clock position of the gastric cross section. Place the anastomotic site into the gastric cavity from the broken end of the stomach. The operator should drag the traction line and move with the stapler at the same time to avoid prolapse of the stapling head (Fig. 14.8), piercing through the posterior wall of the gastric tube. Insert an oval forceps from the posterior incision after successful puncture, with the puncturing head removed (Fig. 14.9). Insert the nail anvil holding forceps from the posterior auxiliary operativeport, fixing the anastomotic anvil, and closing it by rotating the instrument (Fig. 14.10).
