Surgical Approaches to Remove the Esophagus: Minimally Invasive

Indications and Contraindication for Minimally Invasive Esophagectomy

Patients' selection for MIE is similar to the classic open esophagectomy. Accurate staging is warranted to tailor treatment to the extension of disease, and multimodality treatment is recommended for locally advanced cancers. Timing of esophagectomy after induction chemoradiation is important to allow patients' complete recovery yet avoiding disease progression and potential technical difficulties and late complications related to treatment. Surgery is therefore performed approximately 6 to 8 weeks after completion of induction therapy similarly to the open esophagectomy. There are no absolute contraindications to a minimally invasive approach; however, extensive abdominal or thoracic adhesions can make the approach difficult to perform, extension of the tumor in other structures or organs can be difficult to assess due to lack of tactile feedback and single lung ventilation is preferred—although not always necessary—to maximized exposure.

The most important prerequisites to perform an MIE are the institutional availability of advanced minimally invasive equipment and the surgeon's skill with minimally invasive procedures. This operation is, in fact, technically demanding, and a significant learning curve is necessary to limit complications. Improved surgical and oncologic outcomes are usually achieved after 35 to 40 cases. A recent British general consensus reported that the appropriate learning curve to perform MIE is estimated to include between 20 and 50 cases.

Minimally Invasive Ivor Lewis Esophagectomy

In the Western world, the minimally invasive Ivor Lewis approach is the most commonly used because the adenocarcinoma of the lower esophagus is the most prevalent subtype in the United States and Europe. This approach is a particularly well-suited technique for this tumor, which often does not require a complete esophageal resection, and it is also our preferred option for this disease.

The first description of a complete minimally invasive Ivor Lewis esophagectomy was reported in 1999 when Watson et al. performed a laparoscopic and thoracoscopic esophagectomy with an intrathoracic handsewn anastomosis.

A summary of our technique is reported in subsequent text.

Abdominal Phase

The patient is positioned supine with a foot board to allow steep reverse Trendelenburg during the procedure. A double-lumen endotracheal tube is placed for lung isolation during the thoracoscopic phase. An esophagogastroduodenoscopy is performed to evaluate the proximal and distal extension of the tumor and the presence of Barrett esophagus and to evaluate the stomach, which will be used for reconstruction. As previously described, we use five abdominal ports and the Nathanson liver retractor to expose the hiatus.

The abdominal cavity and the liver are carefully inspected to rule out any metastatic disease. We start our dissection in the lesser curvature of the stomach by opening the gastrohepatic ligament and exposing the branches of the celiac trunk. A complete lymph node dissection of the hepatic, the left gastric, and the splenic arteries is performed, and the nodes are sent separately to pathology for evaluation ( Fig. 39B.1 ). The left gastric vein and artery are then divided with a vascular stapler. This allows exposure and nodal dissection at the base of the celiac artery and the diaphragmatic crus.

Mobilization of the greater curvature of the stomach includes complete division of the gastrocolic ligament just distal to the gastroepiploic arcade. Dissection is extended to the fundus by dividing the short gastric vessels and phrenoesophageal attachments and to the proximal duodenum by completely separating the colon from the gastric attachments. When the greater curvature is completely mobilized, the stomach is lifted to dissect the retroperitoneal attachments and mobilize the right gastroepiploic pedicle to its base. This maneuver is very important to obtain transposition of the conduit within the chest without tension on the anastomosis. A Kocher maneuver is not routinely performed to avoid conduit redundancy, which may cause herniation of the gastric antrum and duodenum in the mediastinum. After the stomach is completely mobilized, a transhiatal dissection of the esophagus is performed, exposing and carefully removing the paracardial and lower paraesophageal nodes, which are harder to expose from the chest. A Penrose drain is used to encircle the distal esophagus for retraction, and it is left in the mediastinum to help the esophageal dissection during the thoracic phase.

Pyloric drainage can be achieved either with pyloromyotomy or with a pyloroplasty. Our preference is to use botulinum toxin (Botox) percutaneously injected into the pylorus in both the gastric and duodenal side. This technique has shown good results and is very quick to perform.

A 5-cm-wide gastric tube is created by dividing the stomach with multiple firings of a linear stapler, starting below the incisura to allow complete unfurling of the stomach ( Fig. 39B.2 ). Interrupted Lembert sutures can be used to reinforce the gastric staple line and as a way of measuring conduit length after the conduit has been transposed in the chest. To facilitate retrieval from the chest and avoid torsion, the gastric conduit is left undivided at the fundus. Several studies reported an increase risk of ischemia and leak with a too-narrow diameter (3 to 4 cm) of the gastric tube ; however, leaving the entire stomach can lead to severe regurgitation and offers limited length for chest transposition. A 12-French feeding jejunostomy is inserted percutaneously with a Seldinger technique and is fixed to the abdominal wall with five transfascial sutures.