Step 1: Surgical Anatomy
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The azygous vein crosses the esophagus at approximately the junction of the first third and second third of the esophagus. If the azygous vein is unusually large, it should be preserved. The azygous is infrequently a continuation of an interrupted inferior vena cava.
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The lower esophagus is a left-sided structure. Access from the right chest is possible but is difficult from a high right thoracotomy. Dissection of the hiatus and lower esophagus is best performed during the abdominal phase of this operation.
Step 2: Preoperative Considerations
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See Chapter 1 for general preoperative considerations.
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Patients with bulky mid-esophageal tumors, especially who have undergone neoadjuvant chemoradiation, are best treated with a transthoracic approach.
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Patients with very poor pulmonary function (i.e., FEV 1 <40% predicted) may be better served with a thoracoscopic dissection or transhiatal approach.
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The advantages of the Ivor Lewis approach include the direct dissection of a tumor in the chest, good nodal clearance, and less chance for recurrent nerve injury than with a cervical incision.
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Disadvantages include the need for a thoracotomy, life-threatening sepsis that may accompany an anastomotic leak, and a proximal margin that is approximately 3 cm shorter than with a cervical incision.
Step 3: Operative Steps
1.
Laparotomy and Gastric Mobilization
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The entire stomach is dissected as described under “laparotomy” in Chapter 1 .
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A complete Kocher maneuver is performed, including lysis of any adhesions between the gallbladder and duodenum.
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If a T2 (by endoscopic ultrasound [EUS]), or higher, tumor is present, a rim of diaphragm is now incised and included on the specimen. For T1 or intramucosal tumors, it is acceptable to dissect between the hiatus and esophagus.
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Dissection continues in to the lower chest as with a transhiatal dissection. The harmonic scalpel is an ideal instrument to use during this portion of the dissection. The esophagus is distracted anteriorly during posterior dissection, to the right during dissection on the left, and to the left for dissection on the right.
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A pyloroplasty or pyloromyotomy is performed at this point, if at all.
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The conduit may at this point be placed into the right chest for retrieval during the chest phase of the operation. If so, tacking sutures should be placed on the underside of the diaphragm.
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The nasogastric tube is withdrawn. The gastric tube may be created in the abdomen by firing an endovascular stapler across the right gastric artery near the crow’s foot of veins. Sequential firings of a GIA 4.8 mm in height, 80 mm in length stapler are applied starting at the lesser curvature. Care is taken not to overlap staple lines or include too much tissue in a single firing. The staple line is extended to the cardia of the greater curvature, leaving 6 cm of gross margins.
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The section of staple line where stapler firings overlap is reinforced with interrupted, imbricating 3-0 silk sutures.
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The mobilized stomach is passed into the chest for later retrieval.
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If a gastric tube has been created during the abdominal portion of the operation, it is sutured with heavy 0 sutures to the staple line of the specimen, which includes the distal esophagus and cardia of stomach.
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A J-tube is constructed, and the abdomen is closed.
2.
Right Thoracotomy
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The patient is positioned in the left lateral decubitus position. A posterolateral thoracotomy is performed. The latissimus is divided and the serratus spared. Entry into the chest is through the fourth interspace; the fifth rib is shingled posteriorly.
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At a place in the esophagus remote from the tumor, the esophagus is encircled with a Penrose drain.
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Traction is placed on the Penrose opposite the area of esophageal dissection.
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To the right of the esophagus, all tissue medial to the azygous vein is included in the specimen—branches from the aorta are clipped on the aortic side, and cauterized on the esophageal side. All tissue is dissected of the pericardium and included in the specimen. The Penrose is used to distract the specimen away from surrounding tissue.
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On the left, the esophagus is dissected off the pericardium, and then away from the left main bronchus. On the right and posteriorly the esophagus is dissected off the aorta, clipping all large branches.
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The anterior vagus nerve is divided at this level and dissection proceeds in between the vagus nerve and esophagus.
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The posterior (left) vagus nerve is also identified and dissected away from the esophagus.
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The azygous vein is divided with an endovascular 2.5-mm stapler.
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The upper line of the division is chosen, usually at the level of the divided azygous vein. Minimal dissection of the esophagus is performed above the planned area of division. The gastric conduit is brought into the chest. If the gastric tube has not yet been created, then it is fashioned at this point.
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The length of gastric conduit should be estimated. If there is excess length, the conduit should be trimmed so that the redundant conduit will not kink in the lower chest.
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The anastomosis may be performed using a 25-mm or 28-mm EEA stapler. The upper esophagus is divided with a 3.5-mm stapler, and the staple line is removed. The A 2-0 Prolene is used to secure the anvil in the esophagus. Additional stitches may be used to secure the circumferential suture line. The tip of the gastric conduit is removed, and the handle is inserted into the enterotomy. At a comfortable point on the greater curvature of the tube (opposite the staple line), the handle is united with the anvil, and the stapler is fired. ( Figure 2-1 )
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