Step 1: Surgical Anatomy
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The minimally invasive esophagectomy incorporates either thoracoscopy, laparoscopy, or both, for dissection and reconstruction of the esophagus.
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An EEA anastomosis can be done in the chest, or the conduit may be pulled into the neck for a cervical anastomosis. The equivalent of the tri-incisional approach is described here.
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Thoracoscopic dissection combines the benefits of a thorough lymph node dissection in the chest with less discomfort than seen with open thoracotomy.
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Patients with bulky tumors or tumors of the mid-esophagus (abutting the trachea) are best approached by open thoracotomy.
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Ability to tolerate one-lung anesthesia is essential for adequate visualization during thoracoscopic dissection. Typically this is not a concern even for patients with low FEV 1 , unless they are on preoperative oxygen.
Step 2: Preoperative Considerations
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See Chapter 1 for general preoperative considerations.
Step 3: Operative Steps
1.
Thoracoscopy
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The patient is placed in the left lateral decubitus position and tilted forward approximately 15 to 20 degrees. Thoracoscopy incisions are performed with the aid of a ring clamp inserted through the skin and used to retract tissues. Muscle layers are carefully cauterized.
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A 10-mm camera port is placed in the midaxillary line in approximately the seventh intercostal space. This first incision should be made under direct vision with blunt entry into the through the pleura to avoid any cautery injury to the underlying lung.
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A 10-mm incision is made in approximately the 4th interspace anterior axillary line.
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A 10-mm incision is made in the 8th or 9th interspace, in line with the tip of the scapula.
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A 5-mm port is placed immediately below the tip of the scapula in approximately the 6th or 7th interspace. ( Figures 5-1 and 5-2 )
Figure 5-1
Figure 5-2
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A #0 Endo Stitch is placed in the central tendon of the diaphragm, and is brought out through a small stab incision in the anterior 8th interspace for inferior retraction of the diaphragm.
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The lung is retracted anteriorly with a fan retractor through the 4th interspace port.
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Most of the dissection is performed with a 5-mm grasper introduced through the port immediately underneath the tip of the scapula, and the ultrasonic shears or 10-mm clipper are inserted through the lower posterior port.
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The inferior pulmonary ligament is divided with cautery.
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The pleura posterior to the esophagus is incised with hook cautery along the length of the esophagus.
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An atraumatic grasper is used to pull the esophagus anteriorly.
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10-mm clips are used to ligate all arterial branches and lymphatic tissue posterior to the esophagus.
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The ultrasonic scalpel is used anterior to the clips.
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The lower esophagus is distracted posteriorly and the harmonic scalpel is used to dissect the periesophageal tissue away from the pericardium.
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Lifting the esophagus up, the esophagus is encircled with a Penrose drain that may be knotted or stapled.
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The Penrose drain is grasped via the 5-mm port, and ultrasonic scalpel dissection proceeds cranially. Care is taken at the level of the carina and trachea. In general, the insulated side of the ultrasonic shears should be next to trachea when dissecting near the trachea.
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The azygous vein is dissected free with a large right-angle instrument and is divided with an endovascular stapler.
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The vagus nerves at this level are identified and separated from the esophagus.
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The Penrose drain is advanced cranially within the vagus nerves.
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Dissection proceeds to the level of the thoracic inlet, and the knotted Penrose drain is left in the inlet along the spine.
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An additional Penrose drain is placed for retraction, and dissection proceeds toward the diaphragm, which is not opened so as to allow for an adequate pneumoperitoneum during the laparoscopic phase of the dissection.
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A 28F straight chest tube with an additional side hole is placed, the lung is reinflated, and the ports are closed using a 2-0 suture layer on latissimus, 2-0 suture in the subdermal layer, and 3-0 or 4-0 suture in the subcuticular layer.
2.
Laparoscopy
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The patient is placed supine, and the arms are tucked. A padded footboard is placed and the patient is placed in reverse Trendelenburg position. The patient’s neck is extended. The surgeon stands to the patient’s right.
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Five abdominal ports are used.
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A 12-mm incision is made midway between the midline and right midclavicular line, in the upper abdomen. The anterior fascia, posterior fascia, and peritoneum are opened sharply.
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Additional 5-mm ports are placed laterally on the right (for liver retraction), opposite the 12-mm port on the left, and in higher subcostal positions on the right and left. ( Figure 5-3 )
