Operative indications

Esophageal resection is the only definitive treatment for esophageal cancer. Most Ivor Lewis MIEs are performed for esophageal adenocarcinoma because of the predominant localization of esophageal adenocarcinoma at the GEJ or distal esophagus. Ivor Lewis MIE is also adequate for most esophageal squamous cell carcinomas in the mid or distal esophagus. Ivor Lewis MIE may not be ideal for upper-third or midesophageal cancers with significant proximal extension because resection with adequate margins may be difficult. In these cases, a modified McKeown MIE may be a good alternative. Distant metastatic disease is also a contraindication for esophagectomy, and careful preoperative and intraoperative assessment for peritoneal and liver metastases is necessary before proceeding with resection.

Esophagectomy may also be performed in patients with Barrett esophagus with high-grade dysplasia. In patients with diagnosis of high-grade dysplasia or early-stage tumors confined to the mucosa (T1a), satisfactory results have also been reported with endoscopic mucosal resection, radiofrequency ablation, and laparoscopic transgastric stripping of esophageal mucosa (see Chapter 6). Thus far, however, there have been only a few reports with good follow-up, and even these only report short- to intermediate-term outcomes. Although endoscopic mucosal resection and radiofrequency ablation offer several immediate benefits to the patient, there are concerns that subsquamous Barrett esophagus may still progress to adenocarcinoma, and continued surveillance endoscopy is required. When endoscopic mucosal resection is performed for early-stage tumors confined to the mucosa, incomplete resection is a concern. Moreover, high-grade dysplasia is often multifocal, and there is a high rate of occult carcinoma in patients who undergo resection for the preoperative diagnosis of high-grade dysplasia. Therefore, we continue to offer MIE for multifocal high-grade dysplasia and early-stage adenocarcinoma. We reserve other ablative therapies for those patients who are unwilling to undergo esophagectomy or are poor candidates for surgery.

Ivor Lewis MIE should be considered as a final option for several benign esophageal conditions when other treatments have been ineffective and the patient’s quality of life is significantly affected. These indications include recalcitrant strictures, end-stage achalasia, and gastrointestinal reflux disease that has failed traditional antireflux approaches.

Preoperative evaluation, testing, and preparation

Esophagogastroscopy with biopsy is essential for diagnosis of esophageal adenocarcinoma and for surgical planning but cannot assess the depth of the tumor or lymph node involvement. Computed tomography (CT) and [18]F-fluoro-2-deoxy-D-glucose positron emission tomography (PET) scans should be used to assess locoregional lymph node involvement and distant metastasis. The fused PET-CT modality combines metabolic and anatomic information and improves the accuracy of staging. Endoscopic ultrasound (EUS) is the most accurate noninvasive test for locoregional staging of the cancer (T and N classification). Fine-needle aspiration (FNA) can be added as needed to improve accuracy. We routinely assess the depth of the tumor and the nodal involvement by EUS and FNA. Flexible bronchoscopy should be performed in patients with tumors located in the upper and middle thirds of the esophagus to look for tumor infiltration of the airway.

Before esophagectomy, the patient’s physiologic status should be thoroughly evaluated to assess the risks of the surgery. This evaluation should include assessments of the patient’s cardiovascular and pulmonary function and performance and nutritional status. In most patients, a cardiac stress test should be performed. Baseline pulmonary function tests with arterial blood gas values should be obtained in patients with suspected or documented chronic lung disease. A forced expiratory volume in 1 second (FEV₁) of less than 1 L (about 40% of that predicted for an average man) suggests a higher likelihood of serious pulmonary complications. For selected patients, consultation with cardiology and pulmonary medicine experts may be necessary to develop a treatment plan that balances the risks for cardiac complications with the risk-to-benefit ratio of cardiac intervention, the need for anticoagulation or antiplatelet therapy, and the risk-to-benefit ratio of esophagectomy.

Patient positioning in the operating suite

Patient positioning changes for the three phases of the Ivor Lewis MIE. During the “on-table” esophagogastroduodenoscopy (EGD) before starting resection, the patient is supine. For the laparoscopic portion of the MIE, the patient is positioned supine in steep reverse-Trendelenburg with a footboard in place. The surgeon stands on the patient’s right, and the assistant stands on the patient’s left. For the thoracoscopic portion of the procedure, the patient is repositioned to the left lateral decubitus position. The surgeon remains to the right of the patient, and the first assistant remains to the left of the patient.

Placement of trocars

For the laparoscopic portion of the procedure, six abdominal trocars (three 5 mm and three 10 mm) are placed. First, a 10-mm port through a Hasson technique in placed in the right paramedian position. In the average patient, this approximates two thirds the distance from the xiphoid to the umbilicus. In obese patients with a very protuberant abdomen, this two-thirds distance must be reconsidered, and the port likely will have to be moved closer to the upper abdomen. The pneumoperitoneum is established and maintained at a pressure of 15 mm Hg. In patients with cardiopulmonary compromise, the pneumoperitoneal pressure may have to be lowered to under 10 mm Hg. The remaining ports are then placed. A 10-mm port is placed 5 cm to the left of the operating port (30-degree camera port); a 10-mm port is placed 6 cm below the Hasson port to facilitate placement of the jejunostomy tube; and 5-mm ports are placed subcostally on the right and left midclavicular lines (tissue grasper ports). Finally, we place a 5-mm port, for liver retraction, in the right flank, just below the costal margin laterally (Fig. 4-1).

FIGURE 4-1 Port placement for the laparoscopic phase of Ivor Lewis minimally invasive esophagectomy.

(From Wizorek JJ, Awais O, Luketich JD: Minimally invasive esophagectomy. In Zwischenberger JB, editor: Atlas of Thoracic Surgical Techniques, 1st edition. Philadelphia, 2010, Saunders, pp 305–319.)

For the thoracoscopic portion of the Ivor Lewis MIE, five ports are used (Fig. 4-2). Correct thoracoscopic port placement is critical because poorly positioned trocars lead to difficulty maneuvering instruments through the rigid chest wall. A 10-mm port is placed in the eighth intercostal space on the posterior axillary line. This is used as the laparoscope port. A 10-mm working port for the ultrasonic shears is introduced in the ninth intercostal space, 6 cm posterior to the posterior axillary line—just inferior to the tip of the scapula. Ultimately, this port is enlarged to a 5-cm access incision to enable passage of the end-to-end anastomotic stapler and removal of the specimen. A 5-mm port is inserted posterior to the scapular tip, and through this port, the surgeon provides countertraction, using instruments held in his or her left hand. A 10-mm port is inserted in the fourth intercostal space on the midaxillary line, and the surgeon uses this port for retraction during the esophageal dissection. Finally, a 5-mm port is inserted at the midaxillary line near the sixth rib to be used as a suction-irrigator port.

FIGURE 4-2 Port placement for the thoracoscopic phase of Ivor Lewis minimally invasive esophagectomy.

Operative technique

On-Table Esophagogastroduodenoscopy

After intubation with a double-lumen endotracheal tube, the on-table preoperative EGD is performed with minimal insufflation to avoid gastric and intestinal distention. This EGD is important to confirm the anatomic location and extent of pathology as well as ensure the suitability of the gastric conduit.

Laparoscopic Phase

The laparoscopic portion of the procedure is carried out first. Patient positioning and port placement were described previously. A thorough laparoscopic exploration is performed to evaluate for the presence of occult metastatic disease, and then gastric mobilization is carried out. The gastrohepatic ligament (lesser omentum) is first divided, and the right and left crura of the diaphragm are dissected. The GEJ is mobilized, and then the esophagus is dissected circumferentially in the lower mediastinum. The greater curvature of the stomach is then mobilized by first dividing the short gastric vessels, followed by division of the gastrocolic omentum while carefully preserving the right gastroepiploic arcade (Fig. 4-3). The mobilized stomach is retracted toward the liver. The mobility of the pylorus can be used as a good guide for the adequacy of dissection. If the pylorus easily reaches the right crus and caudate lobe of the liver, the mobilization is generally adequate. If there is any tension during this maneuver, then remaining attachments between the posterior wall of the stomach and the pancreas may have to be divided. An extensive Kocher maneuver may be necessary to accomplish complete pyloric-antral mobilization. Prior gallbladder surgery frequently limits the pyloric-antral mobility, requiring additional adhesiolysis in this area. Next, a complete celiac lymph node dissection is performed, continuing along the superior border of the splenic artery and pancreas toward the splenic hilum. The lymph node packet is included in the specimen. The left gastric vessels are then identified, dissected, and divided with the use of a laparoscopic stapler with vascular staple load (Fig. 4-4).

FIGURE 4-3 Gastric mobilization.

FIGURE 4-4 Division of the left gastric vessels using a vascular load stapler.

Attention is then turned to mobilization of the pyloric-antral area and subsequent pyloroplasty. During this mobilization, the surgeon must be diligent in identifying and preserving the right gastroepiploic arcade. The pyloroplasty is started by placing two traction sutures (2-0), one superiorly and one inferiorly, on the pylorus with the Endo Stitch (Covidien, Norwalk, Conn.). The pyloroplasty is performed by opening the pylorus longitudinally with ultrasonic shears and closing it transversely with interrupted sutures using the Endo Stitch device in a Heineke-Mikulicz fashion (Fig. 4-5). A 4- to 5-cm diameter gastric conduit is then constructed. Initially, the very thick and muscular antrum is divided with the use of thick tissue staple loads (4.8 mm). This division begins from the lesser curve above the antrum and proceeds toward the fundus. As this division proceeds cephalad, the thickness of the stomach wall decreases, and 3.5-mm staple loads are more appropriate (Fig. 4-6). To facilitate exposure, staple alignment, and conduit length during this step, the assistant grasps the fundus of the stomach along the line of the short gastric arteries and retracts gently cephalad while another assistant simultaneously grasps the antrum and retracts inferiorly (Fig. 4-7). This essentially elongates the entire stomach and provides the alignment necessary to construct a consistent-diameter gastric conduit. It is recommended that 45-mm staple loads be used in creating the gastric conduit to prevent “spiraling,” which may occur with the use of the 60-mm loads. The tip of the gastric conduit is then secured to the specimen using an Endo Stitch. During this step, care is taken to maintain alignment so that subsequent retrieval of the specimen through the hiatus into the chest does not lead to rotation; this maintains perfect anatomic alignment of the gastric conduit, with the short gastric vessels facing the direction of the spleen and the lesser curve staple line facing the right side of the chest.