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

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188 Section III • The Esophagus

◆ Many techniques have been described to complete the cervical esophagogastric anastomo-

sis. Stapled anastomoses have shown a lower incidence of anastomotic leak over hand-sewn

anastomoses. Once an adequate length of stomach (4 to 5 cm) has been mobilized above

the clavicles, the suture line from the lesser curve is oriented toward the patient’s right, and

a traction suture is placed on the anterior wall of the stomach at the lower aspect of the

neck wound (Figures 16-21 and 16-22).

FIGURE 16 –22

Medial rotation

of stomach

FIGURE 16 –21

CHAPTER 16 • Esophagectomy—Transhiatal 189

◆ A 1.0- to 1.5-cm gastrotomy is performed on the anterior gastric wall, 3 to 4 cm distal to

the tip of the fundus lying high in the neck (Figures 16-23 and 16-24).

◆ An atraumatic clamp is placed parallel to the esophageal staple line, keeping the oblique

orientation to ensure the anterior portion of the esophagus is longer than the posterior por-

tion to facilitate the anastomosis.

Incision in

stomach

Cutting esophagus

to appropriate angle

FIGURE 16 –23

FIGURE 16 –24

190 Section III • The Esophagus

◆ A traction stitch is placed on the anterior corner of the cervical esophagus and pulled

caudad while one arm of the endoscopic gastrointestinal anastomosis (EndoGIA) stapling

device is placed through the gastrotomy toward the fundus and the other arm placed into

the esophagus along its posterior wall. The stapling device is ﬁ red and individual 4-0

absorbable sutures are then placed at the corners of the stapled anastomosis. At this point

the anesthesiologist inserts a nasogastric (NG) tube while the surgeon guides the tube

through the partially completed anastomosis and into the distal stomach (Figure 16-25).

Stomach

Esophagus

Stomach

Esophagus

FIGURE 16 –25

CHAPTER 16 • Esophagectomy—Transhiatal 191

◆ The remaining small opening between the esophagus and gastrotomy is closed in two

layers. A running 4-0 absorbable suture is used for the ﬁ rst layer followed by

interrupted 4-0 Lembert stitches to complete the anastomosis (Figure 16-26).

Stomach

Esophagus

Securing the stomach

and esophagus with

interrupted sutures

Stomach

Esophagus

FIGURE 16 –26

192 Section III • The Esophagus

◆ The neck wound is ﬁ lled with saline and the anesthesiologist gently introduces 50 mL of air

into the NG tube while the surgeon occludes the distal stomach and observes for air bub-

bles at the anastomosis in the neck. The completed anastomosis should lie high in the neck

without tension (Figure 16-27).

3. CLOSING

◆ Before closure, the entire stomach should be inspected for areas of necrosis. The abdominal

fascia is closed with an 0-looped running polydioxanone suture (PDS) or according to sur-

geon preference, then the skin closed with staples. In the neck, a small Jackson-Pratt drain

is placed in the surgical bed and exited through a separate stab incision in the lateral neck.

The platysma is approximated with a running 4-0 absorbable suture, then the skin closed

with a second 4-0 to 5-0 absorbable stitch. A chest radiograph should be obtained in the

operating room to ensure no pneumothorax or hemothorax is present. If pneumothorax or

hemothorax is present, appropriate chest tubes should be inserted.

Aorta

Heart

Stomach

Esophagus

Trachea

FIGURE 16 –27

CHAPTER 16 • Esophagectomy—Transhiatal 193

STEP 4: POSTOPERATIVE CARE

◆ The need for extensive postoperative monitoring in the intensive care unit (ICU) is

based on surgeon preference, patient comorbidities, blood loss, and length of procedure.

However, routine ICU care is not required postoperatively.

◆ Hallmarks to a rapid recovery lie in adequate pain control, physical therapy, and pulmonary

toilet.

◆ The esophagogastrostomy should be evaluated on postoperative day 4 or 5 with a contrast

swallow study. If no leak is present, a diet is initiated and the drain is removed as long as

the output does not increase with feeding.

◆ If an anastomotic leak occurs, the neck incision should be opened and packed with moist

gauze 2 to 3 times daily. The wound is allowed to granulate and close secondarily.

STEP 5: PEARLS AND PITFALLS

◆ Identify and preserve the right gastroepiploic and right gastric arteries during mobilization

of the stomach.

◆ Vagal ﬁ bers around the midesophagus can be difﬁ cult to dissect bluntly. Using the vertebral

bodies posteriorly as an anvil against which to compress tissues can facilitate blunt dissection.

◆ Communicate with the anesthesiologist, especially during transthoracic dissection when

periods of hypotension are common.

◆ Keep dissection close to the proximal esophagus to minimize potential injury to the recur-

rent laryngeal nerves.

SELECTED REFERENCES

1. Orringer MB, Marshall B, Iannettoni MD: Eliminating the cervical esophagogastric anastomotic leak with a

side-to-side stapled anastomosis. J Thorac Cardiovasc Surg 2000;119:277-288.

2. Orringer MB, Marshall B, Stirling MC: Transhiatal esophagectomy for benign and malignant disease.

J Thorac Cardiovasc Surg 1993;105:265-276.

194

STEP 1: SURGICAL ANATOMY

◆ A comprehensive understanding of the anatomy of the esophagus is critical before under-

taking surgical procedures on the esophagus.

◆ Figure 17-1 demonstrates key anatomic features that should be considered before perform-

ing a transthoracic esophagectomy.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Indications for transthoracic esophagectomy include carcinoma, caustic injury with stricture

or dysplastic mucosal changes, and other benign diseases. Most surgeons agree that benign

disease is best treated with transhiatal esophagectomy, which eliminates the risk of intrathoracic

anastomotic leak and spares the patient the discomfort of thoracotomy without compromising

outcomes. If dense adhesions are expected, a transthoracic approach can afford a safer dis-

section of the intrathoracic esophagus under direct vision and eliminate the blind dissection

and potential for massive hemorrhage, which is rarely associated with transhiatal esophagec-

tomy. For tumors of the proximal esophagus and mid-esophagus, a right thoracotomy is pre-

ferred, whereas a left thoracotomy is preferred for distal esophageal tumors.

◆ Advocates of the transthoracic approach for cancer resection point out that a more complete

lymph node dissection can be accomplished by direct visualization of the operative ﬁ eld.

Advocates of the transhiatal approach point to a perceived overall lower morbidity rate.

Despite multiple studies over the years with trends in both directions, the aggregate experi-

ence has shown no difference in morbidity, mortality, or outcome between the transthoracic

and transhiatal approaches. The most important determining criteria are experience of the

surgeon, need for exposure, and patient selection.

◆ Informed consent is obtained and the patient is made nothing-by-mouth status at least 8

hours before the procedure. A bowel preparation can be given to the patient the day before

the procedure in case the colon is needed as a reconstruction conduit. In the operating

room, a radial artery catheter should be used for continuous blood pressure monitoring.

CHAPTER

Esophagectomy—Transthoracic

(Ivor Lewis)

David B. Loran and Joseph B. Zwischenberger

Central venous access is not routinely necessary. However, if access is needed, the

contralateral neck veins should be used to allow the surgeon complete access to the neck

during operation. A double-lumen endotracheal tube is used to deﬂ ate and retract the lung

to facilitate dissection.

◆ General endotracheal anesthesia is mandatory for this procedure.

◆ The patient is placed supine on the operating table with the head slightly extended. A roll

is placed under the patient to slightly elevate the side of the patient in anticipation of a tho-

racotomy. The patient’s arm is either elevated and draped out of the ﬁ eld or prepped into

the ﬁ eld to allow its mobility during the procedures. Alternatively, the patient can be placed

supine during the abdominal portion of the procedure, then re-prepped and draped in the

lateral position for the thoracic portion.

◆ The skin over the entire neck, chest, and abdomen should be prepped with povidone-

iodine (Betadine).

CHAPTER 17 • Esophagectomy—Transthoracic (Ivor Lewis) 195

Tumor in

distal esophagus

Incision

FIGURE 17 –1

STEP 3: OPERATIVE STEPS

1. INCISION

◆ Transthoracic esophagectomy uses two incisions: a midline abdominal incision and a thora-

cotomy. An upper midline supraumbilical incision from the xiphoid process to the umbili-

cus is used to begin the abdominal portion of the procedure. The incision should be

extended cephalad to the left of the xiphoid process to adequately expose the esophageal

hiatus. A self-retaining retractor can facilitate exposure of the upper abdomen.

◆ A right thoracotomy is recommended for a mid-thoracic or upper thoracic cancer. A left

thoracotomy is recommended for a cancer in the lower one third of the thorax or in the

esophagus (Figure 17-2).

2. DISSECTION

◆ The stomach is completely mobilized as previously described for transhiatal esophagectomy

(Chapter 16). A lateral thoracotomy is performed in the sixth to seventh intercostal space and

the lung is retracted cephalad. If a right thoracotomy is used, the azygous vein should be iden-

tiﬁ ed and suture ligated to better reduce the risk of postoperative hemorrhage (Figure 17-3).

Section III • The Esophagus196

Incision

FIGURE 17 –2

CHAPTER 17 • Esophagectomy—Transthoracic (Ivor Lewis) 197

Tumor in

distal esophagus

Esophageal tumor

Left lung

Heart

FIGURE 17 –3

◆ The pleura overlying the esophagus is incised and the esophagus is dissected free from its

bed. A Penrose drain is used to encircle the esophagus and provide retraction during the

dissection. The surgeon should be able to include the lymph nodes surrounding the esoph-

agus in the dissection (Figure 17-4). Care must be taken not to injure the posterior mem-

branous trachea during mobilization of the esophagus or tumor or both. Once the esopha-

gus is mobilized it is transected at a point at least 4 cm proximal to the tumor.

Incision in diaphragm

Anterior vagus nerve

Left bronchus and

pulmonary vein

FIGURE 17 –4