LEFT THORACOABDOMINAL




Step 1: Surgical Anatomy





  • The lower portion of the esophagus deviates to the left of the midline and is most easily accessible via the left chest.



  • Above the level of the inferior pulmonary vein, the esophagus deviates to the right, but can still be accessed through the left chest.



  • 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.



  • 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





  • See Chapter 1 for general preoperative considerations.



  • Patients with very poor pulmonary function (i.e., FEV1 <40% predicted) may be better served with a thoracoscopic dissection or transhiatal approach.



  • 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.



  • The left thoracoabdominal approach allows for simultaneous access to the chest, abdomen, and neck from a single (right lateral decubitus) position.



  • 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.



  • This approach provides for the best visualization of the celiac axis and short gastric vessels.



  • 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



Mar 13, 2019 | Posted by in GASTROENTEROLOGY | Comments Off on LEFT THORACOABDOMINAL

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