Minimally Invasive Esophagectomy Technique

The videos below demonstrate the procedure for a robotic-assisted esophagectomy.

After endoscopy to visualize the extent of disease and suitability of the gastric conduit, the patient is intubated with a double-lumen endotracheal tube and placed in a left lateral decubitus or prone position. Four thoracoscopic trocars are introduced into the right thorax. Three 10-mm ports and one 5-mm port are placed. One 5-mm port is used for retraction and is placed just anterior to the tip of the scapula. The first 10-mm port placed in the seventh or eighth intercostal space anterior to the midaxillary line is for the camera.

The second 10-mm port is positioned at the anterior axillary line in the fourth intercostal space. This is typically used to place the lung retractor. The final 10-mm port, which is used mainly for dissection and coagulation, is placed at the eighth or ninth intercostal space at the posterior axillary line. A fifth 5-mm port can be placed anteriorly at the sixth intercostal space as needed for suction and assistance with the intrathoracic anastomosis (see the image below). ^{[43, 44]}

The first step after setting up accurate port placement and visualization is to place a suture (0-Surgiteck Endostitch) through the central tendon portion of the diaphragm. This suture is then brought out anteriorly and inferiorly through the thorax at the level of insertion of the diaphragm to facilitate retraction and exposure of the distal esophagus and esophagogastric junction (EGJ).

At this point, division of the inferior pulmonary ligament as performed. Achieving dissection onto the pericardium is important, with retraction of the inferior pulmonary vein, to ensure medial exposure and to mobilize the subcarinal lymph nodes and surrounding tissue, as this will be removed with the specimen. Further dissection is carried out through the mediastinal pleura along the hilum to the level of the azygos vein. Once the azygos vein has been dissected circumferentially, it is divided with an endoscopic stapler. ^{[9, 43, 44]}

The next step is to mobilize the esophagus. This is started by dissecting the lateral pleura overlying the esophagus from the azygos vein down to the EGJ, focusing on avoiding injury to the thoracic duct or aorta. By avoiding injury to the thoracic duct, the need for ligation of the duct is obviated. All periesophageal nodes and fat are included with the specimen. A Penrose drain is helpful in completely mobilizing the esophagus, allowing retrieval during neck dissection (see the image below).

To prevent traction injury to the recurrent laryngeal nerves, the vagal trunks should be divided at the level of the azygos vein. Furthermore, aortoesophageal attachments are thoroughly dissected, clipped, and divided.

Next, the lung is inflated, and the tracheal, bronchial, and parenchymal injuries are assessed. Under thorascopic visualization, a 28-French chest tube is placed through the 10-mm camera port. The remaining ports are then removed, and port sites are closed with polyglactin sutures. Using bupivacaine, regional anesthesia is given to the intercostal areas around the port sites. ^{[25, 45]}

The next portion of the procedure is the abdominal laparoscopy. The patient is placed in the supine position and steep reverse Trendelenburg. At this time, the double-lumen endotracheal tube can be replaced with a single-lumen tube. Five ports are needed during this part of the procedure. A 10-mm port is first placed under direct vision in the epigastrium between the xiphoid and umbilicus just to the right of midline. CO₂ insufflation is provided via this port.

Once adequate pneumoperitoneum is obtained, a 10-mm camera can be placed, and the additional ports can be placed under laparoscopic visualization. A 5-mm port is placed just to the left of the midline at the same level as the 10-mm port. The 10-mm camera can be removed, and a 5-mm, 30º camera is placed through the 5-mm port. Additional 5-mm ports are inserted at the right and left subcostal margins. The final 5-mm port is placed at the right flank to allow liver retraction (see the image below). ^{[25, 43, 44, 45]}

At this point, the liver retractor is placed to elevate the left lobe of the liver to allow adequate visualization of the hiatus. The gastrohepatic ligament is divided, and the now exposed right and left crura are dissected until the EGJ is freed. Avoiding dividing the phrenoesophageal ligament this early is important so that pneumoperitoneum is maintained. The gastrocolic ligament is identified and is divided with ultrasonic coagulation shears lateral to the right gastroepiploic arcade.

After this, the short gastric arteries are divided along the greater curvature to allow mobilization of the stomach. Once dissection has reached the left crus, posterior gastroesophageal attachments and gastrocolic omentum are divided, with the right gastroepiploic arcade preserved. The stomach is retracted superiorly to expose the left gastric and celiac vessels. Nodal tissue in this region is dissected out and collected with the specimen. The left gastric artery and vein are then isolated and divided with clips and ties or a vascular stapler.

The next step, after the stomach has been mobilized, is to perform a pyloroplasty. To minimize traumatic injury, the stomach must be handled with care. The pyloroplasty is usually performed in the Heineke-Mikulicz fashion. A suture is placed superiorly and inferiorly on the pylorus to allow retraction. The ultrasonic shears or cautery is then used to create an opening in the pylorus. The opening is subsequently closed with sutures in a transverse interrupted fashion. To allow the pylorus to reach the right crus and obtain adequate mobilization of the gastric tube, the retrogastric and duodenal attachments are dissected as needed (see the image below). ^{[25, 45]}

The gastric tube construction is then carried out as the next step. Creating a gastric tube with a diameter no smaller than 4-5 cm is important. Anything narrower increases the risk of gastric tip necrosis and neck leaks. To create the gastric tube, a vascular-loaded endoscopic gastrointestinal anastomosis (GIA) stapler is first fired across the lesser-curvature vessels toward the incisura, preserving the right gastric vessels. This step determines the diameter of the gastric tube and is based on the angle of the staple line.

Subsequent stapling should be done along a line parallel to the greater-curvature vessels and arcade to maintain a consistent width in the gastric tube and to avoid gastric tube spiraling. The resected portion is attached to the gastric tube with two endosutures placed from the tip of the fundus to the lesser curvature of the specimen minimizing the bulk as this is passed through the hiatus and out the neck incision and avoiding twisting. ^{[25, 43, 44, 45]}

A feeding jejunostomy is then placed. This may require an additional 10-mm port in the right lower quadrant. With an Endostitch, a proximal jejunal limb, determined by first identifying the ligament of Treitz and tracing about 40 cm back, is attached to the left lateral anterior abdominal wall. A 5-French needle catheter is then placed percutaneously into the jejunum (Compact Biosystems, Minneapolis, MN) under laparoscopic visualization. A guide wire is placed through the needle, which is then followed by a jejunal catheter to a distance of about 20 cm.

The feeding tube is then additionally tacked to about 3-4 cm of distance to the anterior abdominal wall for further support. To assess adequate placement, 10 mL of air or water are instilled through the tube. The last part of the abdominal operation is to now divide the phrenoesophageal ligament to facilitate passage of the conduit through the hiatus. ^{[25, 45]}

The final stage of the operation is the neck anastomosis. To start, a 4-cm to 6-cm horizontal neck incision is made above the sternal notch along the cervical crease to expose the cervical esophagus. Platysmal flaps are developed, the omohyoid is divided, and dissection is carried down to the prevertebral fascia. The cervical esophagus is then carefully dissected and retracted medially.

With dissection carried down inferiorly, an open communication to the thoracic inlet should now exist. The Penrose drain from the thoracic procedure should then be brought up through the outlet to complete dissection. The specimen can then be slowly delivered through the neck incision with the gastric conduit. An assistant should visualize the passage of the conduit through the hiatus laparoscopically to ensure adequate and safe delivery.

Once the specimen is delivered through the neck, the two sutures holding the gastric tube to it are divided, and the specimen is removed. The proximal esophagus is mobilized by dividing 1-2 cm below the cricopharyngeal muscle, and then a purse-string suture is placed with an auto-purse-string device (US Surgical, Norwalk, CT).

After the viability of the gastric conduit is ensured, an end-to-end anastomosis (EEA) is performed with a 25-mm EEA stapler; the anvil is placed in the cervical esophagus and the purse-string tied tightly around it while a small gastrotomy is created in the proximal gastric tube. Once the anastomosis is complete, a nasogastric tube is placed under direct vision, and the gastrotomy is closed with an endoscopic GIA stapler.

The last step of the operation is to return to the abdominal cavity and apply gentle traction to the antral area until the cervical anastomosis returns into the neck incision. This also allows removal of the redundant gastric tube in the mediastinum. To prevent proximal herniation of the gastric tube, tacks are applied to attach the gastric tube to the hiatus. Typically, three sutures are placed. One is placed from the greater curvature to the left crus. Another is placed from the lesser curvature to the right crus. The final tack attaches the central edge of the hiatus to the anterior gastric tube.

The cervical anastomosis is irrigated, hemostasis is maintained, and closure of all port sites and the cervical incision is performed. ^{[25, 45]}

The laparoscopic transhiatal esophagectomy begins with the patient supine in the reverse Trendelenburg position, withthe right thorax raised by 30º in case there is need for an emergency thoracotomy. Typically, the surgeon stands between the patient's legs. As with the transthoracic approach, five ports are used. Placement of the first port is along the midline about 5 cm above the umbilicus using a 12-mm port.

Pneumoperitoneum is established and a 30º scope inserted. The remaining ports can now be placed under laparoscopic visualization to avoid intra-abdominal injury. A 5-mm port is inserted at the subxiphoid for liver retraction. Two more 12-mm ports are placed, one on the right midclavicular line (grasping) and the other on the left midclavicular line (dissection). The final 5-mm port is inserted at the left paraumbilical side for additional retraction. ^{[46, 47]}

To start, the left lobe of the liver is retracted, and the lesser omentum is incised and entered. Surrounding lymph nodes and fatty tissue are cleared to adequately visualize the celiac axis and origin of the common hepatic artery and splenic artery. The left gastric artery and vein are dissected and ligated and divided. Then, the left and right crura are dissected, starting at the anterior arcuate ligament. After this, the posterior mediastinum can be entered to continue dissection. Care must be taken to avoid violating the pleura.

Next, the gastrocolic ligament is opened between the stomach and the transverse colon at the origin of the right gastroepiploic artery. Dissection is carried out toward the gastrosplenic ligament, and the short gastric vessels are divided. The fundus is further released by dissection from the superior splenic pole and division of the pancreaticogastric attachments and the posterior vagus nerve.

Dissection is then performed between the posterior stomach up to the first part of the duodenum (see the image below). Gastric tubulization is performed with an endoscopic GIA stapler as described previously along the greater curvature. With a cotton tape, one end is sutured to the tubule apex and the other to the lesser curvature to facilitate pull-through.

Attention is returned to the hiatus, where the distal esophagus is further mobilized circumferentially while the fundus is gently retracted caudally. Included in this step should be division of the phrenoesophageal ligament with mediastinal lymph node dissection up to the level of the carina, again with a large degree of caution to avoid violating the pleura. At this time, a pyloroplasty can be performed as previously described.

In the next stage of this procedure, a cervicotomy is performed along the anterior sternocleidomastoid, and the esophagus is isolated. With mild traction placed on the proximal cervical esophagus, blunt dissection is used to free the cervical esophagus to the thoracic inlet. At this point, the esophagus and gastric tubule can be pulled through the cervicotomy and an end-to-end esophagogastric anastomosis is performed as described previously (see the image below). Finally, a nasogastric tube is inserted, a jejunal feeding tube can be placed, and all incisions are closed as described before. ^{[46, 47, 48]}

A variation in this technique is the use of mediastinoscopy to further free the intrathoracic esophagus from its attachments and obtain a more adequate lymph node dissection. Another technique aides in better esophageal dissection by passing a vein stripper through a cervical esophagotomy down through the esophagus to the staple line and out a small gastrotomy. An anvil is then attached, and the vein stripper is slowly retracted. As the esophagus gets “inverted,” from the retraction, it allows better dissection along the esophageal tract (see the image below).

Once the esophagus is completely inverted and out through the neck incision, the specimen can be divided. A 26-French chest tube is attached to a silk suture that is brought up through the inversion in the posterior mediastinum. The other end of the chest tube is sutured to the gastric conduit, and after proper orientation, the chest tube and the gastric tube are pulled up through the mediastinum to reach the cervical esophagus. ^{[49, 50]}

Luketich et al have begun to use a minimally invasive Ivor Lewis (transthoracic) approach in which the anastomosis is being performed within the thoracic cavity. It has been shown that with the experience of this group, morbidity and mortality are similar to those of procedures done with a cervical anastomosis. Furthermore, Luketich has shown that they have eliminated the risk of recurrent laryngeal nerve injury and minimized pharyngeal and oropharyngeal swallowing dysfunction by using a thoracic anastomosis. ^[51]

Morbidity and mortality from esophagectomy are significant, ranging from 35% to 50% in reported studies. The most common complication is an anastomotic leak, with rates ranging from 8% to 12%. ^{[25, 52, 53, 54]}  This is comparable to the open procedure anastomotic leak rate of 9.1% ^[27] . Luketich et al reported a high narrow gastric tube leak rate of 25.9% in their series; however, they also reported that there was a high incidence in a particular group that had gastric tube diameters smaller than 4 cm. ^[25]

Other complications vary in incidence across studies but include vocal cord palsy (3.6-14%), chylothorax (1.7-9%), gastric tip necrosis (0.8-3.2%) and tracheal tear (0.4-1%). Cardiopulmonary complications most commonly included atrial fibrillation (11.7%), pneumonia (2-21.4%) and pleural effusion (7.7%). Wound dehiscence rarely occurred in about 0-3.7%, and venous thromboembolism was seen in 0.7-1.4%. ^{[25, 52, 53, 54]}

Brown et al compared perioperative complications in minimally invasive McKeown (three-hole) and Ivor Lewis esophagectomy for esophageal cancer. ^[55] The Ivor Lewis procedure caused significantly less severe perioperative morbidity than the McKeown procedure, but the two operations yielded similar rates of serious pulmonary complications and anastomotic leakage. Minimally invasive Ivor Lewis esophagectomy was found to be safe for treatment of esophageal cancer when oncologically and clinically appropriate, with minimally invasive McKeown esophagectomy remaining a satisfactory option when clinically indicated.