Transhiatal esophagectomy was popularized by Orringer in the late 1970s as a less invasive approach to esophagectomy.^1,2 This approach avoids thoracotomy and has been endorsed primarily by nonthoracic general surgeons who perform esophagectomy. For trained thoracic surgeons, the main drawbacks of this approach are the inability to perform an extensive lymph node dissection and the risk of injury to the great vessels and main airways with tumors of grade T3 or greater.^3,4 We describe herein our current technique for transhiatal esophagectomy, which includes minor modifications to the original Orringer technique.

Comparisons of transhiatal versus transthoracic esophagectomy published in the last decade have included retrospective studies,^5,6 prospective studies,⁷ randomized controlled studies,⁸ and meta-analyses.⁹ The published evidence suggests that transhiatal esophagectomy is associated with a reduced risk of pulmonary complications and in-hospital mortality as well as a shortened length of hospital stay, but an increased risk of anastomotic leakage and postoperative vocal cord paralysis. Although there is no clear difference in overall long-term survival, there is an apparent trend toward improved 5-year survival with transthoracic esophagectomy in patients with a limited number of involved lymph nodes.¹⁰ Published data comparing transhiatal esophagectomy with totally minimally invasive esophagectomy is rather limited.^11,12

Transhiatal esophagectomy is performed via an upper midline laparotomy incision and a left neck incision. Unlike the left transthoracic approach, the transhiatal approach offers excellent exposure of the abdominal cavity.^13–15 A generous Kocher maneuver can be performed, allowing the pylorus to extend almost to the hiatus. This helps to provide the length needed to pull the stomach into the neck. A pyloromyotomy or pyloroplasty can be performed easily, helping to decrease symptomatic gastric stasis postoperatively. There is ample exposure to allow a feeding jejunostomy to be created, aiding in postoperative nutrition.

The lack of a thoracotomy incision in transhiatal esophagectomy has potential advantages. The incisional pain associated with thoracotomy is avoided. The need for one-lung anesthesia is obviated. A chest tube is usually not required. These factors may be of particular importance in patients with severe chronic obstructive pulmonary disease, poor pulmonary function, or both. On the other hand, the lack of exposure of the mediastinum limits the surgeon’s ability to fully assess that portion of the surgical field and to perform radical resection.⁴ Moreover, the surgeon’s hand dissects bluntly behind the heart for a significant length of time during the procedure, making this approach more risky intraoperatively in patients with compromised cardiac function.¹⁶

The left neck incision used in transhiatal esophagectomy affords excellent exposure of the cervical esophagus. The esophageal resection can be extended fairly high in the neck, encompassing even high esophageal lesions adequately. The length of gastric conduit required to reach the neck results in higher leak and stricture rates compared with intrathoracic anastomoses. In the event of a cervical esophagogastric anastomotic leak, however, satisfactory drainage is easily obtained by reopening the neck wound, making the clinical consequences less severe than those of an intrathoracic anastomotic leak. Although methods have been described for performing a stapled cervical esophagogastric anastomosis, the lack of an ideally suited stapling device makes these techniques somewhat awkward. The anastomosis is usually hand sewn and may take no more time to complete than a stapled anastomosis.

The left recurrent laryngeal nerve is at risk in transhiatal esophagectomy, and left vocal cord palsy is a well-recognized complication. In addition to increasing the risk of aspiration owing to incoordination of swallowing, vocal cord palsy may reduce the effectiveness of coughing and compromise tracheobronchial toilet. Peristalsis in the proximal esophageal remnant may help to decrease clinically significant gastroesophageal reflux postoperatively. The relatively short length of remaining cervical esophagus after transhiatal esophagectomy may represent less of a barrier to inevitable postoperative gastroesophageal reflux than the longer esophageal remnant found with intrathoracic anastomoses.

The upper midline abdominal incision used in transhiatal esophagectomy affords excellent exposure of the entire abdomen. Unlike the left transthoracic approach, this exposure permits the surgeon to search thoroughly for abdominal metastatic disease before undertaking any resection. Metastases typically may be found in the omentum, mesentery, or liver and may be biopsied readily. In the absence of distant metastatic disease, the exposure afforded by the upper midline incision used in transhiatal esophagectomy allows for complete resection of the left gastric and celiac axis lymph nodes en bloc with the esophagogastrectomy specimen.

The lack of a thoracotomy incision results in virtually no exposure of thoracic or mediastinal structures. To a large extent, dissection of the esophagus is performed blindly and bluntly. Segmental arteries are avulsed close to the esophageal wall, and an adequate radial resection margin is not easily achievable.¹⁷ There is no reliable way to remove lymph node—bearing periesophageal fat en bloc with the specimen.¹⁸ Furthermore, with the transhiatal approach, there is no effective way to examine the lung for metastases. These factors underscore the need to ascertain early-stage disease preoperatively before committing to the transhiatal approach.

The patient’s ability to withstand the procedure and its possible complications should be carefully evaluated preoperatively. Pulmonary and cardiac function should be assessed. Significant carotid artery stenosis and coronary artery disease should be ruled out. As a result of the high incidence of deep vein thrombosis in patients with esophageal cancer, preoperative lower-extremity venous duplex scanning should be considered.

Transhiatal esophagectomy affords little or no exposure of the upper and middle thirds of the thoracic esophagus for the surgeon. To avoid intraoperative airway injury or vascular injury, any possibility of adherence or direct invasion of the tumor into adjacent structures such as the trachea, aorta, or azygos vein should be excluded before undertaking this approach. For tumors arising above the distal third of the thoracic esophagus in particular, a high-quality CT scan with intravenous and oral contrast material is important. More detailed evaluation for tumor invasion into surrounding structures can be achieved with endoscopic ultrasound (EUS). Currently available clinical (preoperative) staging methods may often fail to identify nodal metastases.¹⁹ Unlike approaches that involve a thoracotomy incision, the technique of transhiatal esophagectomy does not permit en bloc mediastinal lymphadenectomy. The transhiatal approach does not afford exposure of any but the most inferiorly located mediastinal nodes.²⁰ Every effort should be made to exclude metastatic tumor involving lymph nodes above the esophageal hiatus, which would result in an unrecognized incomplete resection. The use of CT and PET scans may be helpful.

Patient Preparation

An epidural catheter may be placed before induction of anesthesia to facilitate postoperative pain management. Pneumatic intermittent calf compression boots are applied. With the patient in the supine position under general single-lumen tube endotracheal anesthesia, a Foley catheter and a radial arterial line are placed. Central venous access may be obtained via the right side of the neck.

To confirm the location of the tumor and/or extent of Barrett epithelium, as well as to rule out gastric/duodenal pathology, upper endoscopy may be performed using minimal air insufflation. After removing the endoscope, an 18F Salem sump nasogastric tube is placed, and the stomach is decompressed. A transverse roll is placed beneath the shoulders, and the head is placed on a gel donut and turned to the right. The entire abdomen and left neck are prepared and draped in continuity (Fig. 16-1). An intravenous antibiotic is administered before making the skin incision, and additional doses are given periodically as appropriate throughout the procedure for wound prophylaxis.

Preparation of the Stomach

An upper midline laparotomy incision is made. The peritoneal cavity and abdominal viscera are examined for evidence of metastatic disease or other pathology. The xiphoid process is excised with electrocautery. A Buchwalter retractor is placed. A bladder blade is used to retract the lower sternum cephalad, and Richardson blades are used to retract the rectus muscles laterally (Fig. 16-2). The left triangular hepatic ligament is divided with electrocautery (Fig. 16-3). The mobilized left hepatic lobe is retracted rightward with a wide Deaver blade covered with a laparotomy sponge (Fig. 16-4).

The nasogastric tube is positioned along the greater curvature of the stomach with its tip near the pylorus and is used as a handhold on the stomach. The abdominal esophagus is dissected from its crural attachments with electrocautery, encircled, and elevated on a Penrose drain. Alternatively, for lesions that are possibly directly invading the area of the esophagogastric junction (EGJ), a cuff of diaphragm can be resected with cautery under direct vision. The greater curvature of the stomach is mobilized using a harmonic scalpel, taking great care to avoid injury to the gastroepiploic arcade (Fig. 16-5).

The gastric fundus is mobilized using a harmonic scalpel to divide the short gastric vessels. Divided branches may be reinforced with ligatures or clips. The posterior gastric vessel, a penultimate branch usually well visualized off the splenic artery, is carefully divided and ligated. The left gastric vessels are dissected, reflecting the left gastric lymph nodes toward the stomach. The left gastric vessels are divided using a roticulating vascular stapler (Fig. 16-6).

A generous Kocher maneuver is performed. The serosa overlying the anterior wall of the pylorus is incised with electrocautery, avoiding the great pyloric vein of Mayo. A complete pyloromyotomy is performed using straight Mayo scissors or a #15 blade. Alternatively, a formal Heineke-Mikulicz pyloroplasty may be performed (see Chapter 17).