11.1. Minimally Invasive Esophageal Resection: Patient Position and Room Setup
James D. Luketich, M.D.
Yaron Perry, M.D.
A. Patient Position and Room Setup
1. Laparoscopic transhiatal esophagectomy
a. Position the patient supine on the operating table (Figure 11.1.1).
b. The surgeon stands on the patient’s right side and the assistant stands on the left.
c. Another option is to position the patient in the modified litho- tomy position with the legs extended in stirrups, the hips mini- mally flexed, and the thighs parallel to the abdomen. The surgeon can stand between the abducted legs.
d. Whether in supine or modified lithotomy position, the table is placed in reverse Trendelenburg (20°–30° head up).
e. A video monitor is placed at the head of the table on each side of the patient.
f. The scrub nurse and the instrument table can be positioned at the foot of the table or off the left or right foot of the table.
2. Thoracoscopic and laparoscopic esophagectomy a. Thoracoscopic stage:
1. The patient is intubated with a double-lumen endotracheal tube for single lung ventilation and positioned in the left lateral decubitus position (Figure 11.1.2). The patient is held on the bed using a bean bag and cloth tape. The right arm is placed on pillows or supported with a bar and an axillary roll is placed under the left axilla. The position is similar to that used for a right posterolateral thoracotomy.
2. The surgeon stands on the patient’s right side and the assis- tant stands on the left.
3. Video monitors are placed on both sides of the head of the operating table.
4. The middle and upper portions of the esophagus are mobi- lized with thoracoscopic access through the right chest.
b. Laparoscopic stage:
1. After the thoracoscopic stage has been completed, the patient is placed in the supine position as for a totally laparo- WHE11 6/16/2005 2:13 PM Page 105
106 J D Luketich and Y Perry
scopic esophagectomy (Figure 11.1.1), to permit the laparo- scopic portion of the operation.
2. The surgeon stands on the patient’s right side and the assis- tant stands on the left. The modified lithotomy position is also an option as described in Section A.3 (above). In this case, the surgeon may stand between the patient’s legs.
3. The surgical technique is the same as for the totally laparo- scopic technique except that only the lower esophagus is mobilized with access through the hiatus because the middle and upper parts of the esophagus are mobilized using tho- racoscopy as described above.
Figure 11.1.1. Patient position and operating room setup for laparoscopic tran- shiatal esophagectomy.
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B. Equipment
a. A double lumen endotracheal tube is essential for the thoracoscopic portion of the procedure.
b. A liver retractor is necessary for the abdominal portion of the procedure.
c. Standard laparoscopic/thoracoscopic instruments (including staplers, clip appliers, and energy sources) are routinely used for this procedure.
Figure 11.1.2. Operating room setup for thoracoscopic stage of thoracoscopic/
laparoscopic esophagectomy.
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