Minimally Invasive Esophagectomy: Tips and Pitfalls
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Position of the Patient
The patient lies supine on the bed with a foot rest. This will secure the patient well, especially when a steep reverse Trendelenburg position is required. The patient is placed flush to the right side of the bed. This position adds to the comfort of the operating surgeon and makes the liver retractor more mobile.
Port Placement Pearl: The Rule of Thirds
Mark the patient:
- Subcostal margin, xiphoid, falciform
- Line from xiphoid process to umbilicus, divided in three
- Camera port: two fingerbreadths below mark 2
- Working port right of surgeon: at mark 2
- Rest, same as Nissen
- Right lower quadrant (RLQ) port: The author calls this the feeding tube and conduit port. It will allow one to suture the feeding tube to the abdominal wall and also helps maintain a straight conduit.
The advantage of a minimally invasive approach is the ability to carefully assess the peritoneal cavity prior to resection, with minimal trauma to the body. The author will spend a few minutes examining the liver, omentum, and abdominal wall prior to resection. Any suspicious lesions are biopsied and sent for frozen section evaluation. This prevents futile resections in those with unsuspected metastatic disease.
Step 1: Hiatal Dissection
Pearl: Reduce the Hiatus Hernia
The author begins this dissection like they do in patients with a hiatus hernia. As the most common cause of esophageal cancer is chronic gastroesophageal reflux disease, it is not surprising that many patients have hiatal hernias. Using the “anterior sac approach,” the author reduces the stomach. This will allow for using more of the stomach to create the conduit.
- Tip: After the hiatus is reduced, the author mobilizes the fibers at the angle of His. Like in all foregut procedures, this makes short gastric mobilization easier as it allows for more mobility of the stomach and improved exposure of the vessels.
- Tip: The author performs minimal esophageal dissection at this time. As many patients have had radiation treatment, the dissection planes between the periesophageal tissue and the pleura are often obliterated. Inadvertent pleurotomies will result in a floppy diaphragm, which can be very bothersome for the rest of the procedure.
Step 2: Mobilization of the Stomach
Pearl: Mobilization With Minimal Grasping of the Stomach
Grasping trauma to the stomach is a common criticism of the minimally invasive esophagectomy (MIE). During an open esophagectomy, the stomach is frequently manipulated by the hand, which minimizes iatrogenic trauma. Without this luxury, overly aggressive grasper manipulation can lead to a beaten-up conduit with significant microvascular trauma. This may lead to leak and/or vascular ischemia. To avoid this, the author prefers to use a minimal touch technique to completely mobilize the stomach.
Pearl: Creation of the Omental Flap
The omental flap extends from the halfway point of the gastrocolic omentum to the short gastrics. It allows the surgeon to cover the conduit staple line and the anastomosis. Obviously, it is critical to avoid the colon wall during this dissection.
The Left Gastric Artery
Pearl: The Left Gastric Artery Post
- Prior to dissecting the left gastric artery (LGA), it is important to clear the right crus off the esophagus. This will allow one to encircle the artery more easily.
- Once this is done, use the left hand to lift the lesser curve of the stomach anteriorly, 2 - 3 cm distal to the gastroesophageal junction. This always demonstrates the contour of the LGA. The actual vessels may not be visible. However, the peritoneum, nodes, and fatty tissue around the artery will be appreciable.
- Once the LGA lymphovascular bundle has been posted, the author scores the peritoneum at the base and sweeps all the tissue anteriorly.
- This will create a nice tunnel for the vascular stapler, along the base of the vessel, below the lymph nodes, and underneath the esophagus.
- This avoids individual dissection of the nodes and allows for a nice en-block resection.
Step 3: The Conduit
- Pearl: The RLQ port. The RLQ is needed for the feeding tube. However, it is of critical importance for the creation of the gastric conduit because of the downward traction that it provides. The port is placed at McBurney’s point, making sure to avoid the inferior epigastric artery.
- Pearl: Consider using a green (Ethicon-Thick Tissue) staple load for the first staple firing along the lesser curve. This may prevent dehiscence in a typically thick area of the stomach.
- Run the staple line parallel to the lesser curvature, maintaining a conduit between 3 - 4 cm in maximal diameter.
Pearl: The Conduit Stretch
After the second gastric firing for the conduit, it is common for the stomach to start folding in on itself and for the stapling angles to be challenging. Creating a nice straight staple line is important for its integrity and length.
- The assistant is handed the apex of the stomach and pulls toward the left upper quadrant.
- The scrub nurse or second assistant gently grasps the staple line and pulls toward the RLQ (using the RLQ port).
- As one staples, they should reposition the stomach to ensure the stomach is not folding within the stapler.
Step 4: The Feeding Tube
The author always places a feeding tube. Feedings are slowly begun 24 hours after surgery. The author uses the percutaneous Barone feeding jejunostomy set and the Endo-Stitch to place the feeding tube 25 cm distal to the ligament of Treitz.
- Pearl: Feeding tube saline push. It can be occasionally challenging to thread the feeding tube distally. Once the feeding tube in inserted into the lumen, it is only advanced 4 - 5 cm. The guidewire and inner cannula are then removed. A 60 cc syringe filled with saline is attached to the feeding tube. The assistant pushes the saline through the feeding tube as they advance it. This creates a stream of saline that helps the tip of the feeding tube travel as distally as possible.
Pearl: Perform Extensive Mediastinal Esophageal Dissection Prior to Turning the Patient
Prior to turning the patient and tacking the conduit, the author strongly recommends extensive mediastinal dissection. The exposure through the hiatus is usually excellent, and the distal esophagus can often be mobilized safely to the inferior pulmonary vein.
Pearl: Two-Point Tacking, Recreating Normal Anatomy
In order to prevent a twisting of the conduit as it is pulled up into the right hemithorax, the author sutures the conduit to the specimen at two spots, 1 cm apart.
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