Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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178 Section III • The Esophagus

◆ The cervical dissection begins by placing an incision along the anterior border of the left

sternocleidomastoid muscle from the hyoid bone to 1 cm above the clavicle. The incision

is carried through the platysma to expose the deep cervical fascia (Figure 16-6).

◆ The sternocleidomastoid muscle and carotid sheath are retracted laterally while the thyroid

gland and trachea are retracted medially to expose the proximal esophagus. Occasionally the

middle thyroid vein and inferior thyroid artery need to be divided for adequate exposure.

Care should be taken to avoid excessive retraction or placing instruments in the tracheo-

esophageal groove, where the recurrent laryngeal nerve can be injured (Figure 16-7).

Incision

FIGURE 16 –6

Recurrent laryngeal nerve

Esophagus

Trachea

FIGURE 16 –7

CHAPTER 16 • Esophagectomy—Transhiatal 179

◆ The cervical esophagus is mobilized by blunt dissection, beginning in the prevertebral

space and working medially. The tracheoesophageal groove is opened with blunt dissec-

tion that is continued medially to connect with the prevertebral dissection (Figures 16-8

and 16-9).

Thyroid gland

Internal

jugular vein

Common carotid artery

Recurrent laryngeal nerve

Esophagus

Trachea

Common carotid artery

FIGURE 16 –8

Thyroid gland

Internal

jugular vein

Common carotid artery

Recurrent laryngeal nerve

Esophagus

Trachea

Common carotid artery

FIGURE 16 –9

180 Section III • The Esophagus

◆ Now that the proximal and distal esophagus is mobilized, the transhiatal dissection is

begun to fully mobilize the remaining esophagus is continued. Continuous traction is

placed on each of the Penrose drains encircling the ends of the esophagus while the sur-

geon bluntly develops the prevertebral plane with his or her right hand through the hiatus

and left hand through the cervical incision (Figure 16-10).

FIGURE 16 –10

Descending aorta

Esophagus

Tumor at distal end of esophagus

Stomach

Heart

FIGURE 16 –10

CHAPTER 16 • Esophagectomy—Transhiatal 181

Esophagus

Thoracic duct

Azygos vein

Cisterna chyli

Heart

SVC

FIGURE 16 –11

◆ A Penrose drain is looped around the esophagus and retracted superiorly while blunt

dissection of the esophagus is continued to the level of the carina. Dissection can be

performed under direct vision through the enlarged hiatus, by blunt ﬁ nger dissection, or

using a thoracoscope (Figure 16-11).

182 Section III • The Esophagus

◆ A sponge on a stick can help facilitate this dissection from the cervical incision. Once

the entire posterior esophagus is mobilized, the anterior section is mobilized in similar

fashion. During the anterior dissection, the surgeon must be careful not to injure the

membranous portion of the trachea. The lateral esophageal attachments can be freed

under direct vision from the hiatus with superior retraction of the chest wall. Lymph

nodes in the subcarinal area should be dissected free and removed with the specimen. If

the lateral attachments cannot be viewed, an alternative method is to insert the surgeon’s

right hand through the hiatus and pin the esophagus against the spine between the in-

dex and middle ﬁ ngers. The lateral tissue is then stripped from the esophagus by blunt

dissection (Figures 16-12 to 16-14).

Diaphragm with

radial incisions for

enlargement

Esophagus

FIGURE 16 –12

CHAPTER 16 • Esophagectomy—Transhiatal 183

Diaphragm

Esophagus

Heart

FIGURE 16 –13

Diaphragm

Esophagus

FIGURE 16 –14

184 Section III • The Esophagus

◆ Once the esophagus is fully mobilized, the cervical esophagus is divided obliquely with a

gastrointestinal anastomosis (GIA) stapling device (Figure 16-15).

◆ The esophagus is pulled from the posterior mediastinum and delivered into the abdomen.

At this point the surgeon should inspect the surgical bed for bleeding and insert a gauze

pack into the posterior mediastinum to tamponade any minor oozing while the stomach is

prepared. The fundus and distal greater curve of the stomach are grasped and held on ten-

sion while the esophagus is pulled at a 90-degree angle. A GIA stapling device can be used

to resect a portion of the lesser curve and gastric cardia to gain a 4- to 6-cm margin from a

distal esophageal tumor. For benign disease, only the cardia is resected to maximize collat-

eral ﬂ ow through the stomach. This process also “tubularizes” the stomach in preparation

for use as a conduit. The staple line can be oversewn with 3-0 silk interrupted Lembert

stitches (Figure 16-16).

FIGURE 16 –15

Esophagus

5 cm

FIGURE 16 –16

CHAPTER 16 • Esophagectomy—Transhiatal 185

◆ The stomach is then manipulated through the enlarged hiatus to the cervical incision. A

Babcock clamp can be inserted from the cervical incision into the posterior mediastinum to

help grasp and deliver the fundus of the stomach into the neck (Figure 16-17).

FIGURE 16 –17

186 Section III • The Esophagus

◆ Alternatively, a Penrose drain can be sutured to the apex of the stomach and delivered into

the cervical incision to help provide traction. Both techniques use more pushing from the

diaphragm side rather than pulling from the neck side. The surgeon must be careful to

avoid twisting the stomach, which will compromise gastric blood ﬂ ow and can lead to con-

duit necrosis with anastomotic breakdown (Figures 16-18 to 16-20).

◆ The abdominal portion of the procedure is completed before the cervical anastomosis is

performed. This allows time to assess the viability of the gastric conduit. In the abdomen,

the hiatus is closed by approximating the crura with 2-0 Vicryl ﬁ gure-of-eight stitches to

easily allow 2 ﬁ ngerbreadths between the stomach and hiatus. The stomach is also tacked

to the diaphragm with interrupted 3-0 silk stitches to prevent subsequent gastric herniation

into the chest. At this point a jejunostomy feeding tube can be placed according to surgeon

preference.

Stomach

Heart

FIGURE 16 –18

CHAPTER 16 • Esophagectomy—Transhiatal 187

Diaphragm

Stomach

Esophagus

FIGURE 16 –19

Stomach

Esophagus

FIGURE 16 –20