Operative indications

Barrett esophagus with high-grade dysplasia on endoscopic biopsy is an indication for esophageal mucosal resection. A segment of Barrett esophagus longer than 5 cm may require a combined endoscopic and laparoscopic approach.

Preoperative evaluation

The objectives of the preoperative evaluation include (1) confirming the diagnosis of Barrett esophagus with high-grade dysplasia, (2) evaluating for hiatal hernia, (3) evaluating for neoplasm or dysmotility, and (4) determining the patient’s suitability for the operation.

A chest radiograph may demonstrate a hiatal hernia and provide information about its size and contents. Concomitant lung disease can be identified as well.

An upper gastrointestinal contrast study will provide information on the anatomy of the esophagus and stomach, which is especially helpful when there is an associated hiatal hernia. In addition, an upper gastrointestinal study can provide direct evidence of the extent of gastroesophageal reflux disease. In the hands of an experienced radiologist, the study can also provide information on the patient’s esophageal motility.

An esophagogastroduodenoscopy (EGD) permits direct evaluation of the esophagogastric mucosa. Biopsies of the mucosa can confirm the presence of Barrett esophagus with high-grade dysplasia as well as the presence or absence of cancer. The EGD can also verify the presence of a hiatal hernia.

If the patient has a large hiatal hernia, then a computed tomography scan of the chest is helpful in delineating the anatomy and contents of the hernia sac, including the presence of organs other than the stomach.

Positioning and placement of trocars

The patient is placed in a modified French lithotomy position with 30-degree reverse Trendelenburg (see Fig. 5-1 in Chapter 5). The surgeon stands between the patient’s legs, the camera operator stands to the patient’s right, and the first assistant stands to the patient’s left. Five trocars are placed as shown in Figure 6-1. The initial port (number 1) is placed using the optical trocar in the left midclavicular line subcostally and serves as the surgeon’s operating right hand. Subsequent trocars are placed in the order numbered two through five. The basic principles of trocar position and use should be followed: The camera port (number 5) is in the midline superior to the umbilicus. The surgeon’s left-hand working port (number 2) is placed in the right subcostal region in the midclavicular line. The retraction port for the assistant (number 3) is placed in the left midaxillary line caudad to port number 1. Trocar number 4 is used to retract the left lateral lobe of the liver and is placed in the subxiphoid region.

FIGURE 6-1 Port placement for the performance of esophageal mucosal resection.

Operative technique

The left lobe of the liver is retracted with the use of an inflatable balloon retractor. The esophageal hiatus is visualized. If a hiatal hernia is present, the contents of the hernia are reduced by gentle traction, and the hernia sac is mobilized and excised. The esophagus is circumferentially mobilized and reduced into the abdomen for 3 to 5 cm. In addition, the esophagus is mobilized to an additional 5 cm in the mediastinum. This mobilization of the esophagus allows for a safer dissection of the esophageal mucosa later. If there is an inadvertent esophageal perforation, this may be diagnosed and addressed immediately. Following the circumferential mobilization of the esophagus, a 5-cm transverse gastrotomy is made 4 cm caudad to the gastroesophageal junction. The lumen of the esophagus and the location of the Z-line are visualized through the gastrotomy. A 30-degree laparoscope is indispensible in performing the operation.

A solution of epinephrine and normal saline (1 : 100,000) is injected with a retractable hypodermic needle system at the Z-line of the distal esophagus to aid in the elevation of the mucosa (Fig. 6-2). The submucosal plane is entered with a modified hook electrocautery instrument; the hook is completely insulated except for the superior edge to allow contact with the underlying muscular layer and not cause thermal injury (Fig. 6-3). The mucosa is dissected further from the underlying smooth muscle with a curved laparoscopic spatula (Fig. 6-4). The mucosa is circumferentially dissected and excised in four quadrants. The mucosal segment is then excised using hook scissors. The tapered end of a lighted bougie (Medovations Inc., Milwaukee, Wis.) maneuvered by laparoscopic forceps is used as a retractor for exposing the four quadrants of mucosa (Fig. 6-5). The excised mucosa is oriented and marked for proximal and distal pathologic orientation. The raw surface of the esophagus is irrigated profusely, and any bleeding is controlled with cautious use of electrocautery. The esophageal wall in the area of mucosal resection is checked for intactness.

FIGURE 6-2 Submucosal injection of epinephrine and normal saline (1 : 100,000).