Laparoscopic transhiatal esophagectomy for adenocarcinoma of the lower esophagus

Conventional esophagectomy requires either a laparotomy with a transhiatal dissection or a laparotomy combined with thoracotomy and it is associated with significant morbidity and mortality. In the attempt to decrease morbidity, some surgeons have reported the application of minimally invasive technique of resection of the esophagus. De Paula was the first to report a large series of 48 patients undergoing a total laparoscopic transhiatal esophagectomy (LTH). LTH may be used to treat patients with either benign or malignant esophageal disease because the reconstructive result cervical esophagogastric anastomosis yields good functional outcomes. Here we show the case of a LTH for adenocarcinoma of the lower esophagus.

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Laparoscopic   transhiatal   esophagectomy   for   adenocarcinoma   of   the   lower   esophagus

Authors
B Dallemagne, S Perretta, J Marescaux
Abstract
Conventional esophagectomy requires either a laparotomy with a transhiatal dissection or a laparotomy combined with thoracotomy and it is associated with significant morbidity and mortality. In the attempt to decrease morbidity, some surgeons have reported the application of minimally invasive technique of resection of the esophagus. De Paula was the first to report a large series of 48 patients undergoing a total laparoscopic transhiatal esophagectomy (LTH). LTH may be used to treat patients with either benign or malignant esophageal disease because the reconstructive result cervical esophagogastric anastomosis yields good functional outcomes. Here we show the case of a LTH for adenocarcinoma of the lower esophagus.
Keywords
Laparoscopic transhiatal esophagectomy, adenocarcinoma, lower esophagus
Media type
Duration
27'40''
Publication
2010-01
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E-publication
WeBSurg.com, Jan 2010;10(01).
URL: http://www.websurg.com/doi-vd01en2794.htm

Laparoscopic   transhiatal   esophagectomy   for   adenocarcinoma   of   the   lower   esophagus

2. Greater curvature and posterior gastric mobilization 01'02''
For division of the gastrocolic ligament, the most useful instrument is the 10mm Ligasure®, and of course during this part of surgery, it’s very important to avoid any contact or any grabbing of the vascular arcade of the gastro-epiploic vessels because these vessels will be used later to provide blood supply. Usually this division starts on the big part of the stomach and then depending on the position of the operator, it can be extended up to the gastric fundus. The most difficult part usually is to find the right plane when we have to deal with the gastrosplenic ligament but more is the best so it’s better to work at a distance from the gastric wall. The posterior fundic ligament is also divided and that will give access to the spleen, the short gastrics, and of course the gastrophrenic ligament. On the right side of the patient, the division will be extended while preserving of course the arcade and the dissection will be followed up to the right gastro-epiploic artery, which has absolutely to be respected. Usually division of the gastrocolic ligament on the right side is important because it increases the mobility of the first duodenum. When needed, the duodenal and pancreatic mobilization can be helpful in order to get some more length of the gastric transplant. Then we move back to the superior border of the pancreas. The retroperitoneum is incised and lymphadenectomy will be performed on the celiac trunk. Progressively the left gastric vessels will be isolated and divided. Small veins are divided with the Ligasure®. Larger veins can be ligated or clipped. Usually we don’t rely on the Ligasure® system to seal the larger vessels so that’s why we sometimes apply clips plus division with the Ligasure®. En bloc lymphadenectomy will be performed at the origin of the left gastric artery. For tumors of the esophagus, we do not routinely perform lymphadenectomy on the splenic artery. The dissection is progressively extended in order to reach the diaphragm and usually the landmark is the crura of the diaphragm.
3. Hiatal dissection with transhiatal circumferential esophageal mobilization with accompanying lymphatic tissue 05'39''
Here we can see the right crus so the lymphadenectomy of the low esophagus starts at this point or the meso of the esophagus has to be dissected free and will be resected with the specimen. The second step of the operation is the esophageal mobilization and of course the lymphadenectomy. The lesser omentum is incised in order to achieve a wide access to the diaphragmatic hiatus. The diaphragm can be incised in order to increase the access in the mediastinum. The incision of the diaphragm can be performed on the anterior aspect or we can also divide the right crus that will facilitate the passage of the gastric transplant. Opening of the mediastinum is made in the usual fashion. The rule is to work on the side of the pleura in order to achieve a good excision of all the tissues surrounding the esophagus. The usual goal is to try to avoid opening of the pleura during this dissection and of course in the majority of cases some injuries of the pleura, right or left, are observed during this intramediastinal dissection. For a long time, there has been a controversy regarding the approach for esophageal cancer of the lower third, some people like Orringer defending the transmediastinal transdiaphragmatic approach, other people like Skinner, like DeMeester defending the idea of an ‘en bloc’ transthoracic esophageal dissection. The latest follow-up and studies on the results of both approaches did not show any significant differences at least for the tumor of the lower third of the esophagus. Of course, the tumor of the middle third of the esophagus can be approached by this transdiaphragmatic transhiatal route. Once this initial part of the dissection is achieved, a drain is passed around the GE junction. This drain is quite important because it will help in the retraction and exposure during the difficult part of the operation, which is the esophageal mobilization of the lower third and usually this transmediastinal approach allows us to go up to the subcarinal lymph nodes. The use of the Ligasure® is quite comfortable because it’s an atraumatic instrument. The sealing of the small vessels that exist in this area is very efficient. At this stage of the operation, another team is starting on the neck of the patient in the left area of the neck and on the anterior relief of the sternocleidomastoid muscles, an incision is made and progressively the proximal esophagus will be identified. On this picture, we can see clearly some adhesions between the right pleura and the peri-esophageal tissues and we can also observe this leak in the right pleura. There is no attempt to close this leak but of course at the end of the operation, thoracic drainage will be put in place. The dissection progresses on the anterior aspect of the aorta. Of course at this stage of the operation the risk is to injure the thoracic duct, which usually lies on the side of the aorta.
7. Cervical esophago-gastric anastomosis 17'40''
On the neck, the plastic bag is detached and a hand-sewn esophagogastric anastomosis is performed. We keep one little corner of the gastric transplant in which we will introduce another gastric tube that will be left in place in the gastric tube during the first days after surgery. The advantage is that this tube is extracted through the skin and so the patient has drainage of his transplant without any nasogastric tube. Another drainage will be left in place just next to the anastomosis. So in the neck, this patient has his drainage plus the gastric tube. This technique is usually very comfortable for the patient and probably reduces the rate of pulmonary infection due to micro-inhalation on the usual nasogastric tube. Then the cervicotomy is closed layer by layer. Then back to the laparoscopic approach, all the peritoneal cavity is checked for bleeding. We fix the gastric tube with 2 or 3 separate stitches to the hiatus and the crura in order to prevent migration or some sort of para-tube herniation. So with this technique, the gastric tube is drained with this gastric probe, which is placed through the neck in the conduit. No drainage is left in the peritoneal cavity but a drainage is left in the right chest because of the opening of the right pleura. The gastric drainage is maintained till recovery of the bowel movements. Then an upper GI series is performed usually between day 5 and day 7 and in this patient, the pathology revealed an adenocarcinoma with good lymph node clearance.