Subtotal En Bloc Esophagectomy Abdominothoracic Approach

Stefan B. Hosch, Asad Kutup, Jakob R. Izbicki

Introduction

The goal of this operation is to remove an esophageal cancer with the widest possible lymphatic clearance (two-field lymphadenectomy), which comprises upper abdominal lymphadenectomy and lymphatic clearance of the posterior and mid mediastinum. Reconstruction is accomplished by either gastric tube or colonic interposition.

Indications and Contraindications

Indications ■ Thoracic esophageal carcinoma

■ Benign stricture, if transhiatal resection is ill-advised (e.g., adherence to trachea)

Contraindications ■ See chapter on "Subtotal Esophagectomy: Transhiatal Approach"

■ High risk patients

Preoperative Investigation/Preparation for the Procedure

See See chapter on "Subtotal Esophagectomy: Transhiatal Approach".

Procedure Access

■ Patient in left lateral positioning for the thoracic part of the operation

■ Anterolateral thoracotomy through the 5th intercostal space (ICS)

■ Re-positioning to a supine position (see chapter on the transhiatal approach)

■ Upper transverse incision with median extension (see chapter on the transhiatal approach)

STEP 1 Thoracotomy and incision of the pleura along the resection line

Thoracotomy through the 5th ICS with skin incision from the apex of the scapula to the submammarian fold (A).

Two retractors are positioned stepwise. Single left lung ventilation is performed. The mediastinal pleura is incised along the resection line for the en bloc esophagectomy. Incision starts from the pulmonary ligament, circumcising the dorsal part of the right hilum of the lung and along the right bronchus. It follows the right main bronchus at the lateral margin of the superior vena cava up to the upper thoracic aperture. Then the incision line changes direction caudally along the right lateral margin of the spine, down to the diaphragm along the azygos vein. It is of the utmost importance to identify the right phrenic nerve (B).

STEP 2 Division of the pulmonary ligament

For exposure of the pulmonary ligament the lung is pushed cranially and laterally. All lymphatic tissue should be moved towards the esophagus. Care has to be taken not to injure the vein of the lower lobe of the right lung.

Liver Right Lobe Mobilization

STEP 3 Ligation of the azygos vein

The superior vena cava and the azygos vein are dissected. Suture ligation towards the vena cava and ligation of the azygos venal stump are performed.

Suture Ligation Artery

STEP 4 Radical en bloc lymphadenectomy

Lymphadenectomy starts from the superior vena cava up to the confluence of the two vv. anonymae. Dissection of the bracheocephalic trunk and right subclavian artery is followed by dissection of the right vagal nerve and identification of the right recurrent laryngeal nerve. Caudal to the branching of the recurrent laryngeal nerve, the vagal nerve is transected and the distal part is pushed towards the en bloc specimen. Then lymphadenectomy is performed continuously along the dorsal wall of the superior vena cava (A).

Thoracic Lymphadenectomy

Radical en bloc lymphadenectomy

After having completed preparation of the superior vena cava, the trachea and the right-and right-sided main bronchus are completely freed from lymphatic tissue. The pre-and paratracheal fat and lymphatic tissue are dissected towards the esophagus (B).

Dissection of the retrotracheal lymph nodes is then performed. Injury of the membranaceous part of the trachea has to be carefully avoided while removing these nodes towards the esophagus (C).

Esophagus Abdominothoracal

Radical en bloc lymphadenectomy

Lymph node dissection continues with the upper paraesophageal lymph nodes (D).

All intercostal veins that drain into the azygos vein are ligated and divided. Lymphadenectomy of the subcarinal lymph nodes is then performed with dissection of the left main bronchus (E).

Thoracic Duct Ligation

Radical en bloc lymphadenectomy

Para-aortic lymphadenectomy is performed. The esophageal branches of the thoracic aorta have to be dissected very carefully and should be ligated with suture ligation (F).

Identification and careful dissection of the thoracic duct is done with double ligations directly above the diaphragm and at the level of the main carina (G).

Subtotal Esophagectomy

Radical en bloc lymphadenectomy

Mediastinal lymphadenectomy is completed with the removal of the left sided paraaortic and retropericardial lymph nodes, as well as the intermediate and lower lobe bronchus down to the esophageal hiatus (H).

After complete mobilization of the esophageal specimen, thoracic drainage is placed in the right thoracic cavity. After closure of the thoracic incision the patient is reposi-tioned for the abdominal part.

Esophagectomy Incision

For the abdominal and cervical parts: see the transhiatal approach.

Alternatively an intrathoracic anastomosis can be achieved (see chapter on intra-thoracic anastomosis).

See chapter "Subtotal Esophagectomy: Transhiatal Approach" for standard postoperative investigations and complications.

Tricks of the Senior Surgeon

■ In case RO resection cannot be accomplished, the retrosternal reconstruction route is preferred.

■ If the trachea is injured, use a direct suture and pericardial flap.

■ For better exposure of the cervical esophagus, transect the medial head of the sternocleidomastoid muscle.

■ Injury of [he gastroepiploic arcade directly necessitates colonic interposition.

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