Open Transhiatal Esophagectomy

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Author: Jennifer Tseng
Published:
Specialties: General Surgery
Schools: University of Chicago
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Basic Info

Contributors: Mitchell C. Posner

Open transhiatal esophagectomy

DOI: http://dx.doi.org/10.17797/6ob5owtokl

Editor Recruited By: Jeffrey Matthews, MD

Advanced

Procedure

A midline laparotomy incision is made after laparoscopic exploration is proven negative for metastatic disease. An OMNI Wishbone retractor is positioned for wide exposure. The triangular ligament is divided. The gastrocolic omentum and short gastric vessels are divided with cautery, ENSEAL or 2-0 silk ties preserving the right gastroepiploic vessels and the posterior stomach is freed of its attachments. A wide Kocher maneuver is performed. The left gastric vessels are divided and all lymphatic and nodal tissue is swept off the celiac axis and crus of the diaphragm, dividing the remaining short gastric vessels. The peritoneum is incised over the gastroesophageal junction, which is encircled with umbilical tape. A left neck cervical incision is made at the anterior-medial border of the sternocleidomastoid muscle and carried through the platysma, with the Weitlaner retractor used for exposure. The omohyoid muscle is divided and dissection is conducted medial to the jugular vein and carotid artery into the prevertebral space. The esophagus is encircled with a penrose drain, identifying and preserving the recurrent laryngeal nerve in the tracheoesophageal groove. Dissection is carried out under direct vision to the innominate vessels circumferentially. Returning to the abdomen, dissection is carried off both crus of the diaphragm and after division of the inferior phrenic vein the diaphragm is incised anteriorly providing wide exposure to the lower mediastinum to facilitate the lymph node dissection under direct vision up to the carina. With further blunt dissection between the carina and cervical incision the esophageal mobilization is complete. The nasogastric tube is pulled back to the cervical esophagus. The cervical esophagus is divided with a GIA stapler with a longitudinally marked Penrose drain for orientation. The distal esophagus is brought through the mediastinum with the Penrose drain and the esophagus/stomach are exteriorized through the abdominal incision. The lesser curve is cleared of all lymphatic tissue and a gastric tube is formed with multiple applications of the GIA stapler with 4.8mm staple loads. The specimen is removed. An automatic purse-string applier is placed on the cervical esophagus and a 25mm EEA anvil is placed in the cervical esophagus and the purse-string suture secured. The Penrose drain is attached to the stomach with 3-0 silk sutures, and the stomach is transposed through the mediastinum into the cervical incision. An anterior gastrotomy is made and the EEA instrument is passed into the stomach with the trocar brought out the posterior wall of the stomach. The EEA instrument is attached to the anvil in the cervical esophagus, closed and fired and 2 complete donuts are confirmed. Excess stomach is excised with a TA-60 stapler. The nasogastric tube is repassed through the anastomosis. The incisions are then closed, placing unilateral/bilateral chest tube(s) if necessary and a feeding tube.

Indications

Esophageal cancer, high-grade dysplasia, neuromotor dysfunction (achalasia, spasm/dysmotility, scleroderma), stricture (gastroesophageal reflux, caustic ingestion, irradiation), recurrent hiatal hernia, recurrent gastroesophageal reflux, acute perforation, acute caustic injury.

Contraindications

Too high risk for major surgery, inadequate pulmonary reserve, lack of adequate conduit, tracheobronchial invasion

Instrumentation

Setup

The patient is placed in supine position, left arm tucked. The neck is hyperextended. The head is positioned on a foam donut and turned towards the right side (the endotracheal tube should be taped towards and any central line is also inserted on the right side). Sequential compression devices, a Foley catheter and a nasogastric tube are placed prior to incision. The OMNI Wishbone retractor post is set up on the left side of the bed.

Preoperative Workup

Review relevant endoscopic and CT scan imaging and reports.

Anatomy and Landmarks

See Procedure

Advantages/Disadvantages

Advantages: avoids thoracotomy incision, shorter duration of surgery compared with Ivor-Lewis approach, decreased pulmonary complications, eliminates risk of mediastinitis from anastomotic leak Disadvantages: higher rate of recurrent laryngeal nerve injury, increased rate of anastomotic leak, post-operative strictures

Complications/Risks

Intra-op: mediastinal bleeding, tracheobronchial injury, conduit ischemia Early: hoarseness from injury to the recurrent laryngeal nerve, chylothorax, anastomotic leak, atelectasis/pneumonia, atrial fibrillation, wound infection/dehiscence Late: dysphagia, regurgitation, postvagotomy "dumping," anastomotic stricture

Disclosure of Conflicts

none

Acknowledgements

n/a

References

Barreto JC, Posner MC. Transhiatal versus transthoracic esophagectomy for esophageal cancer. World J Gastroenterol. 2010;16(30):3804-10.

Orringer MB, Marshall B, Iannettoni MD. Transhiatal esophagectomy for treatment of benign and malignant esophageal disease. World J Surg. 2001;25(2):196-203.

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