Figure 43-8. A: Transhiatal mobilization of the thoracic esophagus from the posterior mediastinum with the use of blunt dissection

and traction on rubber drains placed around the esophagogastric junction and cervical esophagus. The volar aspects of the fingers

are kept against the esophagus to reduce the risk for injury to adjacent structures. B: Lateral view showing transhiatal mobilization

of the esophagus away from the prevertebral fascia. Half of a sponge on a stick is inserted through the cervical incision and

advanced until it makes contact with the hand inserted from below through the diaphragmatic hiatus. Arterial pressure is

monitored as the heart is displaced forward by the hand in the posterior mediastinum.

Figure 43-9. The stapled technique for cervical esophageal anastomosis. This technique results in lower anastomotic leak rates and

fewer postoperative strictures.

Minimally Invasive Esophagectomy

Some surgeons have combined a thoracoscopic approach with a laparotomy, while others reported a

laparoscopic abdominal component with an open thoracotomy for the chest. While these hybrid

operations do fall under the umbrella of minimally invasive esophageal resection, a strict definition of

minimally invasive esophageal resection avoids both a thoracotomy and a laparotomy completely. In

our experience, we initially started with a laparoscopic transhiatal approach (in 15 patients) and

attempted to reach our finger dissection from the neck incision. We found this to be quite difficult in

most patients. We then converted to a combined thoracoscopic/laparoscopic approach with a neck

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anastomosis, as it afforded better visualization of the periesophageal structures especially near the main

airways and subcarinal areas, was less affected by patient height and body habitus, improved our ability

to do a more complete nodal dissection, and greatly improved overall visualization compared with the

totally laparoscopic method. This minimally invasive three-field (McKeown approach) operation was

our procedure of choice for 6 to 8 years (approximately 500 cases). Following this extensive minimally

invasive experience, we moved to a minimally invasive Ivor Lewis approach in which we start

laparoscopically and complete using a right thoracoscopic approach and a high thoracic anastomosis. We

prefer this approach because the avoidance of a neck dissection essentially eliminates recurrent

laryngeal nerve injury. Additionally, minimally invasive Ivor Lewis resection allows a more aggressive

gastric resection margin; amputation of the most proximal tip of the newly constructed gastric conduit,

which is the most susceptible to ischemia and potential leak; and performance of the anastomosis with a

wide view within the chest cavity.75,76

8 In 2000, Nguyen et al. compared MIE with open transthoracic esophagectomy and transhiatal

esophagectomy (THE). Shorter operative times, less blood loss, and shorter stays in the ICU with no

increase in morbidity were documented with the minimally invasive approach as compared with the

open approach. Over the past several years, several series have been published on minimally invasive

resections that demonstrate comparable survival outcomes compared with large open series.77

Indications for the minimally invasive approach for esophagectomy include Barrett esophagus with

high-grade dysplasia, end-stage achalasia, esophageal strictures, and esophageal cancer. While most T4

esophageal cancers are generally not amenable to open or minimally invasive surgical approaches,

cancers of all other T stages are potentially amenable to MIE in experienced hands. Esophageal cancer

that has been downstaged after neoadjuvant chemoradiation is also potentially resectable by a

minimally invasive approach but, as with open operations in this setting, can be technically more

difficult than nonirradiated fields. Previous thoracic and abdominal surgery is not necessarily a

contraindication to MIE depending on the extent of the previous surgery and the experience of the

surgeon. The minimally invasive Ivor Lewis esophagectomy works well for most distal esophageal

cancers, short-to-moderate length Barrett with high-grade dysplasia, and gastroesophageal junction

tumors extending onto the gastric cardia. Total laparoscopic and thoracoscopic Ivor Lewis resections

should not be performed for upper third esophageal cancers with significant proximal extension due to

concern for adequate margins of resection. Some midesophageal tumors can be approached with the

Ivor Lewis technique, but a very high intrathoracic anastomosis may be needed to gain a negative

margin.

Anesthetic Considerations

Anesthetic management during MIE poses specific challenges. Whereas all patients receive an arterial

blood pressure monitoring line, central venous catheter placement is not routine. A double-lumen

endotracheal tube is placed initially in anticipation of the thoracoscopic phase. In patients with

midthoracic or upper thoracic tumors, a single-lumen endotracheal tube is initially placed for

preoperative bronchoscopy to evaluate airway involvement.

Patients generally require significant volume loading during the laparoscopic phase secondary to the

pneumoperitoneum and steep reverse Trendelenburg positioning. Given the high flow of CO2

required,

the patient can develop significant hypercarbia and acidosis. The surgeon must also be mindful of

vasopressors administered by the anesthesiologist because these agents directly affect the viability of

the newly created gastric conduit. Simple measures can be undertaken to help correct these problems.

Maneuvers to increase preload include lowering the insufflation pressure, decreasing the degree of the

reverse Trendelenburg position, and increasing volume loading. In addition to changes in the ventilator

settings, hypercarbia can often be corrected by reversing the pneumoperitoneum, allowing the patient

time to compensate and clear the excess CO2

. There must be clear and ongoing communication

throughout the procedure between the surgeon and the anesthesiologist.

Endoscopic Evaluation

The operation begins with a careful EGD. The location of the tumor is confirmed along with precise

measurements of the proximal and distal extent of the lesion. The surrounding esophagus is examined

for evidence of Barrett changes proximal to the intended resection margin, with four-quadrant biopsies

taken in areas of clinical concern. Careful endoscopic examination of the stomach is also imperative to

assess its suitability for use as a conduit in esophageal reconstruction. Air insufflation should be kept to

a minimum during the examination to reduce the degree of small bowel distention which may

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significantly decrease domain and heighten the difficulty of laparoscopy.

Laparoscopic Phase

Positioning and Laparoscopic Port Placement

The patient is positioned supine with the arms out at 60 degrees. A foot board is placed to allow steep

reverse Trendelenburg positioning during the hiatal dissection. The costal margin is identified and a line

is drawn from the xiphoid to the umbilicus. This line is then divided into thirds. The first port is placed

using a direct Hassan cutdown approach in the right paramedian position roughly 2 cm lateral to the

midline at the junction of the lower and middle thirds of the described line. A total of five abdominal

ports are used for gastric mobilization (12-mm right and left paramedian, 5-mm right and left subcostal,

and a second 5-mm right lateral subcostal port for liver retraction (Fig. 43-10) with the remaining ports

placed under direct laparoscopic vision. A sixth port is placed in the right paraumbilical region to assist

in placement of the feeding jejunostomy tube. All ports should be a hand’s breadth apart so as to avoid

interference between instruments. In addition, it is important to keep skin and fascial incisions small so

as to avoid subcutaneous emphysema.

While working at the hiatus, the camera is placed in the left paramedian port position. The surgeon

works from the right side of the table using the right paramedian and subcostal ports. The assistant, on

the left of the table, controls the camera as well as a second grasper for retraction (through the left

subcostal port). The liver retractor is brought in through the right lateral subcostal port and positioned

to elevate the left lobe of the liver and expose the hiatus.

Figure 43-10. Laparoscopic port placement. The 10-mm port is placed first in the right midabdomen using open Hasson trocar

insertion technique. An additional 5/11-mm port is placed in the right lower quadrant that is helpful for retraction during

pyloroplasty and gastric tube creation.

Gastric Mobilization

Thorough inspection of the abdomen is performed to ensure that no injuries were caused during the

process of port placement and to evaluate for intraperitoneal metastasis. The peritoneal lining,

omentum, and liver are visually inspected for abnormalities with biopsies taken of any suspicious

lesions for frozen-section evaluation. The gastrohepatic ligament is opened and the left gastric vascular

pedicle identified (Fig. 43-11). A complete lymph node dissection is then performed, leaving the left

gastric and celiac lymph nodes with the specimen. This dissection is continued laterally along the splenic

artery and the superior border of the pancreas and superiorly toward the crura along the preaortic

plane. If there is a question of potential malignant involvement, these nodes are sent for frozen-section

evaluation to aid in determination of resectability. Once ensured that no nodal disease is present, the

right crus is dissected, allowing lateral mobilization of the esophagus. This dissection is continued

anterior to the esophagus, transecting the phrenoesophageal ligaments and exposing the anterior hiatus.

The left crus may be exposed either by the continuation of this anterior dissection along the medial

crural border or by first mobilizing the fundus of the stomach by division of the short gastric vessels.

Dissection of the left crus is continued posteriorly until the decussation of the right and left crural fibers

is noted. This exposes the retroesophageal window and ensures complete mobilization of the superior

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portion of the lesser curvature and gastroesophageal junction.

After identifying the gastrocolic omentum, the antrum of the stomach is retracted, and a window is

created in the greater omentum, thus allowing access to the lesser sac. The remaining short gastric

vessels are divided, taking care to preserve the right gastroepiploic arcade. The fundus is retracted to

the right and this dissection is continued posteriorly, eventually exposing the left gastric artery and vein

and joining the lesser curve dissection plane to complete mobilization of the stomach. Gastric

mobilization is carried inferiorly to the pyloroantral region. Meticulous attention must be paid during

this phase of the dissection because any injury to the gastroepiploic arcade at this level may render the

gastric conduit unusable. This dissection may be especially difficult in patients who have had

pancreatitis or a history of prior biliary surgery. Adequate mobilization has been achieved when the

pylorus is able to reach the level of the caudate lobe of the liver, which may require either a partial or a

complete Kocher maneuver. The left gastric artery and vein are then divided using an endovascular GIA

stapler. Care should be taken to ensure that all nodes are swept toward the specimen side and to avoid

narrowing of the splenic or hepatic arteries.

Creation of the Gastric Tube

The gastric tube is created prior to the completion of the pyloroplasty and placement of the feeding

jejunostomy tube to allow for an assessment of the viability of the gastric conduit. The gastric tube

follows the arc of the greater curve of the stomach and is based on the right gastroepiploic artery (Fig.

43-12). An endovascular stapling technique allows for a controlled creation of the gastric tube conduit.

The first staple load is placed across the adipose tissue and vessels along the lesser curve, above the

level of the right gastric artery. No stomach is divided in this initial staple firing, which is intended to

provide hemostasis. The subsequent staple firings divide the stomach. We prefer 45-mm staple loads for

this process (purple loads; Endo GIA Reloads with Tri-staple Technology, Covidien, Mansfield, MA)

because the course of the greater curvature can be followed more precisely, resulting in improved

conduit length. An additional grasper is brought through the right paraumbilical port at this time to

assist in the retraction of the stomach during creation of the gastric tube. It is important to keep the

stomach on stretch during this process so as to create a straight conduit. The first assistant grasps the tip

of the fundus along the greater curve and gently stretches it toward the spleen. A second instrument

from the paraumbilical port grasps the antral area with a slight downward retraction. The stomach is

first horizontally divided across the antrum. The staple line is then directed superiorly, toward the

fundus, parallel to the line of the greater curve. A conduit width of 4 to 5 cm is preserved (Fig. 43-13).

The length of the conduit is shortened if there is concern for extension of the tumor onto the gastric

cardia. Sutures may be placed to reinforce the staple line if there is concern about its integrity, although

this practice is not routinely necessary.

Figure 43-11. Laparoscopic staging, with opening of the gastrohepatic ligament and evaluation of left gastric/celiac lymph nodes.

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