Step 1: Surgical Anatomy
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The lower portion of the esophagus deviates to the left of the midline and is most easily accessible via the left chest.
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Above the level of the inferior pulmonary vein, the esophagus deviates to the right, but can still be accessed through the left chest.
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The aortic arch obscures the esophagus when approached through the left chest, but the esophagus can still be mobilized, albeit with more difficulty than via a right thoracotomy.
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The thoracic duct runs behind the junction of the subclavian artery and aortic arch when viewed from the left side and must be avoided.
Step 2: Preoperative Considerations
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See Chapter 1 for general preoperative considerations.
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Patients with very poor pulmonary function (i.e., FEV1 <40% predicted) may be better served with a thoracoscopic dissection or transhiatal approach.
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This approach is useful for tumors of the GE junction and cardia of the stomach. Access to mid and upper third esophageal tumors is much more difficult with this approach, and a tri-incisional approach is preferred.
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The left thoracoabdominal approach allows for simultaneous access to the chest, abdomen, and neck from a single (right lateral decubitus) position.
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This approach is especially useful for GE junction tumors that may have significant extension into both the esophagus and cardia of the stomach. If the stomach margins are positive, a complete gastrectomy with Roux-en-Y anastomosis in the lower chest may be performed. If the esophageal margins are positive, then the stomach may be pulled up into the neck. Complete removal of the stomach and esophagus requires a colon interposition, as Roux-en-Y jejunum generally does not reach into the neck.
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This approach provides for the best visualization of the celiac axis and short gastric vessels.
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Ability to tolerate single lung ventilation is not an absolute requirement as the lower lobe can be mobilized and retracted upward for an anastomosis in the lower chest. Patients with such poor lung function, however, may have fewer pulmonary complications with a transhiatal or thoracoscopic approach.
Step 3: Operative Steps
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The patient is placed in the right lateral decubitus position with the hips rotated about 30 degrees posteriorly.
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A posterolateral thoracotomy incision is made, extending from just behind the tip of the scapula coursing down the seventh interspace. The incision may be stopped at the costal margin, or extended across the costal margin toward the linea alba. Most of the dissection and gastric mobilization can be performed through a generous incision in the diaphragm parallel to the chest wall. The decision to extend the incision across the costal margin and onto the abdomen is based upon the need to perform a Kocher maneuver or pyloroplasty, and any associated abdominal pathology. Some surgeons routinely extend the incision across the costal margin as it makes the dissection easier. ( Figure 3-1 )
Figure 3-1
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An incision is made in the diaphragm, 2 to 3 cm away from the diaphragm’s insertion site in the chest wall. The diaphragm can be taken down with cautery while being elevated with a large right angle clamp to protect intraabdominal structures. Marking sutures should be placed in both sides of the diaphragm as it is divided to allow for realignment during closure. Alternatively, a 3.5-mm thickness stapler can be used. The sites of intersection of stapler fires aids in realignment of the diaphragm when closing. ( Figure 3-2 )
