History
Transhiatal esophagectomy (THE) has been gaining popularity for the past two and a half decades. In 1978 Orringer and Sloan renewed interest in this procedure, presenting it as an alternative approach to the more traditional transthoracic esophagectomy. THE is done without a thoracotomy and the physiologic impact on the body is minimized, resulting in decreased morbidity and mortality rates.
Indications
Patients under evaluation for an esophagectomy should be considered potential candidates for THE. The transhiatal approach to esophagectomy has been used for resection of tumors at any location; however, it is best for tumors in the lower esophagus distal to the membranous trachea and at the esophagogastric junction. This approach allows complete excision of the esophagus without the need for a thoracotomy. Patients post radiation treatment and those with periesophageal adhesions from various causes (caustic injuries, achalasia, previous surgeries) can still undergo THE; however, patients with local invasion of major structures or those with distant metastasis (stage IV disease) are considered unresectable because the risk from the surgery far outweighs the benefits derived from the procedure.
Step 1
Surgical Anatomy
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A comprehensive understanding of the anatomy of the esophagus is essential before any operation on the esophagus. Figure 26-1 outlines the key anatomic structures that must be identified before performing THE.
Figure 26-1
Step 2
Preoperative Considerations
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Efficient preoperative evaluation should include a thorough assessment of the patient’s cardiopulmonary reserve and their operative risk. Exercise stress testing, spirometry, and arterial blood gas should be considered.
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Before esophagectomy is performed, esophagoscopy with endoscopic ultrasound, contrast computed tomography (CT) of the chest and abdomen, and positron emission (PET) scan are required. A barium swallow, especially for initial diagnosis, may also be done.
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A barium swallow is useful for tumor location and assessment of whether there is extension into the proximal stomach. Esophagoscopy enables direct visualization and assessment of the mucosa and allows for procurement of samples for cytology and histology. Endoscopic ultrasound allows imaging and needle aspiration of periesophageal and celiac lymph nodes to complete preoperative staging. CT of the chest and abdomen is used to determine the extent of esophageal thickening and celiac or mediastinal adenopathy and to assess whether there is invasion into the tracheobronchial tree and aorta.
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PET is useful to identify the likelihood of distant metastases when positive, especially the lack thereof when negative. Smoking cessation at least 2 weeks before surgery is advised to minimize complications and facilitate early ambulation. Healthy dentition reduces risk of postoperative infection.
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Nasogastric feedings for nutritional supplementation should be instituted in patients with extensive weight loss and dehydration resulting from severe esophageal obstruction.
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Preoperative jejunostomy feeding tubes and percutaneous gastrostomy complicate gastric mobilization but are preferable to TPN.
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Discussing potential surgical complications with the patient (dysphagia, dumping, reflux, regurgitation, and early satiety) is extremely important to enable the patient to make informed decisions and to cultivate realistic expectations about the surgical outcome.
Anesthetic Management
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Continuous intra-arterial blood pressure monitoring with a radial artery catheter is performed to monitor hypotension caused by cardiac displacement by the surgeon’s hand during intrathoracic mobilization.
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Two large-bore intravenous (IV) catheters are placed in peripheral arm veins for rapid volume resuscitation during the operative procedure. Note that the average blood loss is less than 500 mL.
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An epidural catheter augments postoperative pain management to improve pulmonary function.
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A standard endotracheal tube is used. In the event of a posterior membranous tracheal tear during tumor dissection, the tube can be advanced into the distal trachea or left mainstem bronchus, allowing one-lung anesthesia while the repair is undertaken, thus avoiding a double lumen ET tube.
Step 3
Operative Procedure
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THE consists primarily of three phases: abdominal dissection, cervical dissection, and mediastinal dissection.
1
Abdominal Dissection
Incision
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This phase begins with a supraumbilical incision, which extends from the xiphoid to the umbilicus (see Fig. 26-1 ).
Dissection
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The triangular ligament is divided with retraction of the left lobe of the liver to the right ( Fig. 26-2 ).
Figure 26-2
(From Townsend CM Jr, Evers MB. Atlas of General Surgical Techniques. Philadelphia: Saunders; 2010.)
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Examine the stomach for tumor involvement and scarring or shortening from prior surgeries.
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Identify and protect the right gastroepiploic artery throughout this early procedure, particularly in patients with a history of prior abdominal surgeries.
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Begin separation of the greater omentum from the stomach along the greater curvature of the stomach where the right gastroepiploic terminates as it enters the stomach.
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The greater omentum is then separated from the right gastroepiploic artery with a 2-cm margin.
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The left gastroepiploic and short gastric arteries are ligated and divided, taking care to avoid injury to the gastric wall and the spleen.
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The peritoneum overlying the hiatus is incised, and the esophagogastric junction is mobilized and encircled with a rubber drain.
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The gastrohepatic omentum is mobilized and incised starting from the midpoint of the lesser curvature and moving toward the hiatus.
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After locating, ligating, and dividing the left gastric vein, the left gastric artery is ligated near its origin from the celiac axis.
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In patients with carcinoma, celiac lymph nodes are sent for pathologic staging. The presence of large celiac nodal metastasis is indicative of incurable disease and a biopsy is taken.
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The right gastric artery is protected throughout the mobilization of the stomach.
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A Kocher maneuver is performed to allow mobilization of the pylorus.
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A pyloromyotomy is then performed. Electrocautery and a fine-tipped mosquito clamp are used to dissect the gastric and duodenal muscle away from the underlying mucosa. Some prefer a Heineke-Mikulicz pyloroplasty, especially when adequate length is not a problem.
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Small metal clips are placed at the level of the pyloromyotomy to serve as markers for future radiographic studies.
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Via downward traction on the rubber drain encircling the esophagogastric junction, the distal 5 to 10 cm of esophagus is mobilized through the diaphragmatic hiatus.
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Mobility of the esophagus within the posterior mediastinum is assessed to ascertain that it is not fixed to the aorta, prevertebral fascia, or surrounding mediastinal structures. Three techniques for esophageal mobilization have evolved: (1) blunt dissection along the prevertebral fascia, (2) enlargement of the esophageal hiatus with direct visualization, and (3) thoracoscopic mobilization of the intrathoracic esophagus.
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If there are no contraindications to proceeding, a jejunostomy tube is placed.
2
Cervical Dissection
Incision
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A 5- to 6-cm hockey-stick incision along the anterior border of the left sternocleidomastoid (SCM) is made ( Fig. 26-3 ).
Figure 26-3
(From Townsend CM Jr, Evers MB. Atlas of General Surgical Techniques. Philadelphia: Saunders; 2010.)
Dissection
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The platysma is divided and the omohyoid is exposed.
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The SCM muscle and the carotid sheath are retracted laterally. Blunt dissection is used to reach the prevertebral fascia. If necessary, the middle thyroid vein and inferior thyroid artery may be ligated.
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The recurrent laryngeal nerve lies deep to these vessels; thus no retractor other than the surgeon’s fingers should be placed against the tracheoesophageal groove to avoid injury to this vessel ( Fig. 26-4 ).
