Invasive Esophagectomy
James D. Luketich, M.D.
Yaron Perry, M.D.
A. Introduction
Two different minimally invasive approaches to esophagectomy are pre- sented in this chapter; in both methods the intraabdominal portion of the case is carried out laparoscopically. The first method, the transhiatal approach, avoids entry into the chest; in this case the operation is completed via a neck incision.
In contrast, the second method calls for part of the case to be completed via tho- racoscopic means. Regardless, a single port arrangement suffices for the trans- abdominal portion of both the transhiatal and the thoracoscopic/laparoscopic esophagectomy.
B. Port Placement 1: Laparoscopic Transhiatal Esophagectomy
1. Port placement arrangement
a. Five abdominal ports should be placed (Figure 11.2.1).
b. The initial port (5 or 10 mm) is placed cephalad and to the left of the umbilicus after the abdomen has been insufflated with a Veress needle at this site. This port is used for the laparoscope.
c. An assistant’s port (5 or 10 mm) is introduced at the costal margin lateral to the rectus abdominus muscle on the left.
d. A 5-mm port is placed on the right side in the anterior axillary line just below the costal margin. This port is used for a 5-mm liver retractor to hold the lateral segment of the left lobe of the liver anteriorly and cephalad. This step will provide exposure to the esophageal hiatus.
e. Another 5-mm port is placed at the lateral edge of the right rectus abdominus muscle just caudal to the costal margin. This port is used by the surgeon’s left hand.
f. A 12-mm port is placed superior and to the right of the umbili- cus. This port is used by the surgeon (right hand) and must be 12 mm to accommodate the linear stapler.
Figure 11.2.1.Port arrangement for abdominal portion of both laparoscopic transhiatal esophagectomy and for thoracoscopic/laparoscopic esophagectomy (five ports).
a. Mobilize the stomach by dividing the short gastric arteries, the left gastric artery, and the greater and lesser omentum.
b. Kocherize the duodenum.
c. Mobilize the esophagus through the hiatus.
d. Make a neck incision to remove the esophagus, pull the stomach through the mediastinum, and create an anastomosis between the pharynx or proximal esophagus and the fundus of the stomach.
B. Port Placement 2: Combined Thoracoscopic and Laparoscopic Esophagectomy
1. Port placement
a. Thoracoscopic portion (Figure 11.2.2)
i. Four thoracic trocars are introduced. The camera port (5 or 10 mm) is placed at the seventh intercostal space at the midaxillary line.
ii. A 5-mm port for the ultrasonic shears is placed at the eighth or ninth intercostal space, 2 cm behind the posterior axillary line.
iii. One 5-mm port is placed behind the tip of the scapula.
iv. An additional 5-mm port, for a retractor, is placed in the fourth intercostal space at the anterior axillary line.
v. Next, a single retracting suture, 0-surgitek (US Surgical), is placed in the central tendon of the diaphragm and brought out of the inferior, anterior chest wall through a 1-mm skin nick using a suitable port closure device (suture passer).
b. Laparoscopic Portion
i. After the thoracoscopic portion of the case has been com- pleted, the patient is repositioned into the supine position.
ii. Next, five abdominal ports are placed on the anterior abdom- inal in the same locations as described for transhiatal esophagectomy (see Figure 11.2.1).
Figure 11.2.2. Port arrangement for the thoracoscopic portion of the combined thoracoscopic/laparoscopic esophagectomy. Ports are placed through the chest wall as described in text. None are placed below costal margin.
C. Selected References
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