Oesophageal Cancer
Oesophagectomy
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Introduction
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Experience
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Technique
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Technique
Positioning of the Patient
The patient is supine, legs apart. The patient's head is turned toward the right in hyperextension. The surgeon stands between the patient's legs, the first assistant to the patient's left, the second to his right and the scrub nurse to the left of the patient's left leg. The patient is draped so as to allow trocar placement, the incision along the left sterno-cleido-mastoideus, and the possibility of a fast conversion in right thoracotomy.
Placement of trocars
5 trocars are used. A 10mm, 2cm above the umbilicus. A 10mm on the mid clavicular line under the left costal margin. A 5mm trocar half way between the first two trocars. A 5mm trocar, on right midclavicular line, under the right costal margin and a 10mm under the sternal notch. The trocars harbor a 30° angled scope, a liver retractor, a coagulating hook or the ultracision® and two graspers.
Exposure of the esophagus
The second assistant retracts the left liver lobe thus, exposing the esophageal hiatus. The right pillar is readily seen through the peritoneal covering of the gastrohepatic ligament. Cirrhosis or hypertrophy of the left liver lobe are relative contraindications since cephalad retraction of the liver can be impaired and good exposure of the hiatus rendered difficult. On the contrary no problems are encountered in the obese patient, more specifically in the female patient with a more peripheral distribution of body fat.
Dissection of the esogastric junction
The dissection of the lesser omentum starts to the left of the right gastric artery and follows this one towards the hepatic hilus, follows the left side of the liver until it reaches the right pillar of the right crus. Next dissection of the anterior leaf of the esogastric and the phrenogastric ligament is carried out. Dissection is then performed from top to bottom of the right pillar while resecting a generous chunk of the muscular fibers so as to be certain to stay away from the tumor and to open extensively the hiatus. Finally, dissection is continued downwards this pillar, until the aorta is reached.
Mobilization of the greater curvature
Section of the gastrocolic ligament and thus opening of the lesser sac is carried out just lateral to the right gastro-epiploic artery. The greater curve is completely freed from bottom to top, care being taken so as not to injure the gastro-epiploic artery. Dissection of the gastrosplenic ligament is taken as far as the phrenogastric ligament. The opening in the lesser sac is widened and the posterior aspect of the antrum is dissected up to the level of the pylorus. The mesocolon is now dissected away and the omentum is sectioned. A kocher manoeuvre is performed.
Celiac node dissection and ligation of the left gastric artery
The antrum is attracted downwards. The tail of the pancreas is clearly visualized as well as the celiac trunk and the hepatic pedicle. The peritoneal leaflet joining the tail of the pancreas is dissected with the coagulating hook. All lymphoglandular tissue from that point towards the right is sampled while preserving the pyloric artery and the hepatic pedicule, toward the liver. The portal vein and the hepatic pedicle are skeletonized . The assistant seizes the perivascular fat and attracts it upwards and to the patient's left. The common hepatic artery is skeletonized until the celiac trunk is reached. The left gastric vein is dissected and is sectioned between 2 clips. Dissection of the celiac trunk with the Ultracision towards the pillars, leads to complete mobilization of all attachments of the stomach.
Gastric tubulization
The gastric tubulization is achieved before the intra-mediastinal dissection in order to decrease the operative time with severe impact on the cardio-pulmonary functions. The general outline of the stomach tube is determined by scoring the anterior wall of the stomach. Several applications of stapler are necessary. The first firing begins at the level of the crow’s foot, perpendicularly to the lesser curvature. The second firing of staples is placed in the same way towards the greater curvature, describing an angle in relation to the first, angle that will open up completely while going cephalad, so as to increase the length at the time of the ascension of the plasty. If one considers a neck anastomosis, the section is incomplete and ends some 4 cm from the summit of the fundus. If one considers a thoracic anastomosis, the transsection by the stapler is complete and joins the lesser curvature. The stapler line is buried by several running sutures with the Endostitch (or by hand).
Intramediastinal dissection
A vertical phrenotomy is achieved at the summit of the pillars. The limits of the mediastinal dissection are the following: anteriorly, the pericardium and the left inferior pulmonary vein; on the left side the pleura; on the right side, the right pleura and posteriorly, the aorta. In case of cancer of the cardia, the pleuras are immediately resected. The bilateral pneumothorax is generally well supported. Dissection is performed either with the ultracision® or with the coagulating hook. The dissection is pushed as far as possible, at least until the carina is reached.
The visualization of this dissection requires anterior displacement of the heart by the liver retractor». This manœuvre is sometimes ill tolerated and the retraction must be interrupted regularly so as to recover normal arterial tension.
If one decides to achieve an intrathoracic anastomosis, a cervicotomy is not necessary.
Cervicotomy and esogastric anastomosis
The head is in hyperextension and turned toward the right. Incision is performed at the anterior aspect of the right sterno-cleido-mastoid muscle; the skin, the platisma and the superficial cervical aponeurosis are severed. The retraction of the left thyroid lobe is made with the help of the assistant’s finger in order to avoid the risks of recurrent nerve damage. The cleavage planes were already started by the pneumomediastinum and the esophagus is mobilized by the finger (fig. 8). The extraction of the distal esophagus, containing the tumoral mass and finally of the upper gastric part is achieved under laparoscopic control. One can now establish the level of section of the upper part of the stomach according to the vascularisation and the distance to the tumor (fig. 9). The joint esogastric anastomosis is achieved by hand by a posterior running suture with PDS 4.0 and by separate stitches anteriorly.
This technique seems to be advantageous at least on the short run because it avoids thoracic wall damage and pleural effusion as well as a painful extended laparotomy.
Intrathoracic anastomosis
Two techniques are possible for this anastomosis
- Either partial section of the esophagus, followed by introduction of the anvil in the esophagus and performance of a purse string with the Endostitch.
- Or stapling of the esophagus, followed by introduction of the 25 anvil by the mouth thanks to the process described by Michel Gagner (1).
- In both instances, the next step is introduction of the circular stapler after vertical incision in the gastricremnant. After firing of the stapler, additional stitches can be sewed thanks to the Endostich®.
The section is totaly completed by laparoscopy.