INTRODUCTION — Esophagectomy consists of esophagogastric mobilization with or without lymphadenectomy, conduit construction, resection, and anastomosis. Each component can be performed open or with minimally invasive techniques such as laparoscopy, thoracoscopy, mediastinoscopy, and robotic approaches [1].
In this topic, we describe the technique of totally minimally invasive Ivor Lewis esophagectomy in detail and other techniques briefly (eg, three-field McKeown esophagectomy, transhiatal esophagectomy).
The indications for and complications of esophagectomy are discussed in other topics. (See "Surgical management of resectable esophageal and esophagogastric junction cancers" and "Surgical management of esophageal perforation" and "Complications of esophageal resection".)
MINIMALLY INVASIVE IVOR LEWIS ESOPHAGECTOMY — The operation described here is a completely minimally invasive Ivor Lewis esophagectomy with an intrathoracic esophagogastric anastomosis [2]. Variations of this operation include laparotomy with thoracoscopy, laparoscopy with thoracotomy, and robot-assisted surgery. These are referred to as hybrid minimally invasive esophagectomy.
The minimally invasive Ivor Lewis technique is suitable for most distal esophageal cancers, gastroesophageal junction cancers, and short- to moderate-length Barrett esophagus with high-grade dysplasia. Given concerns about resection margins, the minimally invasive Ivor Lewis esophagectomy should not be performed for upper-third or mid-esophageal cancer with significant proximal extension [2].
Advantages of the Ivor Lewis esophagectomy are a lower rate of anastomotic leak and recurrent laryngeal nerve injury compared with operations with a cervical anastomosis. Disadvantages include the requirement for single-lung ventilation [3].
Abdominal phase — The abdominal phase of a minimally invasive Ivor Lewis esophagectomy is performed via laparoscopy or robotically; we prefer the laparoscopic approach.
Positioning — The patient is placed either supine or in low lithotomy position. If supine positioning is used, the surgeon operates from the patient's right side. If the lithotomy position is chosen, the surgeon mostly operates from between the legs.
Port placement — The arrangement of port placement depends on surgeon preference and patient body habitus. Most commonly, five abdominal ports are used for the intra-abdominal portion of the operation (figure 1). We prefer to add an additional sixth port in the right lower quadrant for conduit creation.
A liver retractor is used to expose the diaphragmatic esophageal hiatus. We place the Nathanson retractor through a 5 mm subxiphoid stab incision.
Diagnostic laparoscopy — The abdominal cavity should be inspected laparoscopically, focusing particularly on diaphragmatic and hepatic implants. The presence of peritoneal, liver, omental, or other metastasis precludes esophagectomy.
Hiatal dissection and lymph node dissection — We prefer to perform this portion of the gastric mobilization prior to dissecting the greater curvature as carbon dioxide introduced into the lesser sac may facilitate entry into the correct plane during gastric mobilization.
●The hiatal dissection begins with opening of the gastrohepatic ligament at the pars flaccida to expose the right crus. This dissection is performed close to the liver to include all pertinent fibrofatty, perigastric tissue as the right crus is approached. The mobilization is typically continued anteriorly, working in a clockwise manner circumferentially around the anterior hiatus, and then down the left crus. The phrenoesophageal ligaments are often divided.
●Attention is then turned to identifying the left gastric artery and vein pedicle (figure 2). Using a blunt-tipped laparoscopic grasper from the leftmost assistant port, the lesser curve is retracted laterally and elevated anteriorly toward the abdominal wall. This maneuver places the left gastric artery on tension and allows its base to be easily visualized (picture 1).
●We then perform a complete lymph node dissection using an energy device. Beginning at the base of the left gastric artery, all nodal and fibrofatty tissue is dissected free and swept toward the gastric specimen. This lymphadenectomy is typically continued along the splenic artery to the splenic hilum and includes the fatty tissue along the superior border of the pancreas, common and proper hepatic nodes, and celiac nodes (figure 3).
●Once the left gastric artery and vein are skeletonized of surrounding tissue and circumferentially dissected, they are divided with an endoscopic vascular stapler. We routinely make sure a visible pulse is present in the hepatic and splenic artery before firing the stapler to ensure that the main celiac axis is not inadvertently divided.
●The hiatal dissection continues until the base of the left crus is identified [4]. Returning to the right crus, the dissection is carried down inferiorly to expose the decussation of the left and right crus. If the periesophageal plane does not develop due to either tumor involvement or postinduction fibrosis, we resect some crural muscle fibers to ensure an R0 resection. We do not identify the vagi nerves, as they require division for an oncological resection.
●After the retroesophageal window is created and the esophagus is encircled with a Penrose drain, further dissection into the mediastinum is halted as violation of the pleural space may lead to laxity of the hemidiaphragm(s), which may compromise visualization or cardiopulmonary function.
Gastric mobilization — The greater curvature of the stomach is dissected next. Adequate dissection of the greater curve can be assured when the pylorus easily reaches the hiatus. At this point the stomach should be completely mobilized, and gastric conduit creation proceeds. (See 'Conduit creation' below.)
●Using a "minimal touch" technique (avoid grasping the stomach as much as possible), a window in the gastrocolic ligament is created about halfway up the greater curvature in order to enter the lesser sac. In patients who have a large amount of omental fat, entry into the correct plane can be difficult during this step; the transverse mesocolon must be protected. We aim to stay at least 3 to 4 cm away from the gastroepiploic vessels (figure 2) to protect both the feeding vessels and the omentum. An omental flap can be used to protect the later esophagogastric anastomosis.
●Once the lesser sac is entered, the greater curvature dissection is continued cranially toward the fundus of the stomach. Eventually, the gastroepiploic artery fades out and the short gastric vessels are reached. These are similarly divided with the energy device.
●After this dissection is completed, the stomach is atraumatically retracted (without grasping) toward the patient's right and anteriorly. This places the retrogastric attachments on tension and allows them to be carefully divided.
●Dissection is then carried through the gastrocolic ligament toward the pylorus. During this step, the right gastroepiploic artery must be protected (figure 2) as it forms the sole blood supply to the gastric conduit. The latter part of this dissection can be particularly difficult in patients with a history of pancreatitis or biliary tract procedures (eg, cholecystectomy). In patients with a lot of omental fat, it is important to avoid injuring the mesocolon.
Conduit creation — We typically utilize a right lower quadrant port for conduit creation.
●We begin our conduit creation at just about the level of the crow's foot on the lesser curvature. The stapling typically starts with a vascular load to divide the lesser curvature fat and small vasculature (picture 2). No gastric tissue is included in this first stapling. The next stapling will be onto the antrum with an appropriately sized tissue stapler load (eg, EndoGIA TriStapler purple loads).
●After the initial gastric stapling, the stomach is put on stretch in order to ensure a straight conduit. This is facilitated by having the assistant grasp the top of the fundus (preferably in an area that will be removed) and retract toward the left upper quadrant. At the same time, countertraction toward the patient's right lower quadrant is applied via a second Penrose drain placed around the stomach (picture 3).
●With the stomach on appropriate tension, the gastric conduit staple line is created with serial stapling toward the fundus, with each stapling parallel to the greater curvature. We aim to create a conduit approximately 4 to 5 cm in width to optimize postoperative conduit function (figure 4). The traction and countertraction need to be adjusted throughout the conduit creation in order to maintain a straight, nonspiraled conduit and to prevent "accordioning" of the stomach.
●We prefer to not completely transect the conduit from the specimen, in order to facilitate transposition of the conduit into the chest during the next phase of surgery. Others completely divide the conduit from the specimen and loosely reattach the two with sutures.
Pyloric drainage procedure — We do not routinely perform a pyloric drainage procedure. It is our preference to endoscopically treat patients with delayed conduit emptying with endoscopic pyloric dilation and/or Botox injections. However, we have found this to be quite rare.
Pyloric drainage (pyloroplasty, pyloromyotomy, Botox) at the time of esophagectomy is controversial [4-6], but randomized trials have failed to show any long-term benefit from surgical drainage procedures [7].
Placement of feeding jejunostomy tube — Routine placement of a feeding jejunostomy tube at the time of esophagectomy has previously been the standard of care due to concerns regarding anastomotic leak due to early feeding and complications relating to total parenteral nutrition [8]. However, feeding jejunostomies can be associated with significant morbidity for patients [9]. As such, the utility of routine placement of feeding jejunostomy tubes has been debated [10-12].
We still routinely place feeding jejunostomy tubes during esophagectomy and have more often than not found them to be beneficial. A feeding jejunostomy can be placed via mini upper laparotomy or laparoscopically.
Mediastinal dissection — Next, with downward retraction on the Penrose drain surrounding the esophagus, a mediastinal dissection is performed up to the level of the inferior pulmonary veins. We have found that a high mediastinal dissection during the laparoscopic portion facilitates the thoracoscopic phase of the operation.
We aim to include within our specimen all fibrofatty and lymph node tissue anterior to the aorta and spine posteriorly, to the posterior aspect of the pericardium. Similarly, the associated left and right pleural envelopes are included in this dissection.
Conclusion of abdominal phase — Prior to closing the abdomen, it is crucial to evaluate and maintain proper orientation of the conduit. It is also important to assess the size of the hiatal opening and reduce it to allow just the passage of the gastric conduit and minimize the risk of paraconduit hernia. The Penrose drain is placed high in the mediastinum for later retrieval during the thoracoscopic phase. Hemostasis is checked and ensured. Prior to closure, we perform bilateral transverse abdominis plane (TAP) and rectus sheath blocks laparoscopically for pain control. The liver retractor is removed, and the abdominal ports are closed.
Thoracic phase — The thoracic phase of a minimally invasive Ivor Lewis esophagectomy can be performed via thoracoscopy or robotically; we prefer the thoracoscopic approach.
Positioning — Once the abdominal portion of the procedure is complete, the single-lumen endotracheal tube is exchanged for a double-lumen endotracheal tube in order to achieve left-sided single-lung ventilation. The patient is then placed in left lateral decubitus position with the right side up. The patient is tilted slightly anteriorly to more easily expose the posterior mediastinum.
Port placement — A variety of ports or incisions can be utilized for the thoracic component of the operation depending on surgeon preference. A common configuration is presented here (figure 5).
Esophageal dissection and lymph node dissection — During intrathoracic esophageal dissection, care must be taken regarding the position of the airway to prevent injury to the membranous portions of the right and left mainstem bronchi. Dissection posterior to the esophagus can cause an injury to the thoracic duct. While it is not our practice to routinely perform thoracic duct ligation, it may be required if an intraoperative chyle leak is suspected. Generous use of metal clips is recommended to seal large lymphatics and aortoesophageal vessels. The surgeon must also be aware of the location of the aorta as this too may be injured with overzealous dissection posterior to the esophagus.
●Prior to mobilization of the intrathoracic esophagus, a retraction suture is often placed through the tendinous portion of the diaphragm to allow inferior retraction and exposure of the distal esophagus in the right thoracic cavity.
●The inferior pulmonary ligament is divided up to the inferior pulmonary vein, and pulmonary ligament (level 9) lymph nodes are harvested (figure 3). With adequate mediastinal dissection previously completed from within the abdomen, the Penrose drain is often easily identified once the inferior pulmonary ligament is taken down. The lung is then retracted anteriorly while the esophagus is retracted posteriorly to allow this dissection to continue along the pericardium.
●The posterior mediastinal pleura is opened superiorly until the inferior border of the azygos vein (figure 6). Dissection of the pleura overlying the esophagus is then transitioned inferiorly to within the posterior groove of the esophagus just anterior to the azygos vein, leaving a swatch of pleura adherent to the specimen. At this point, we often choose to perform our subcarinal lymph node dissection either en bloc with the specimen or separately.
●Next, the azygos vein is divided with a vascular stapler. Following this, the thoracic esophagus is then completely mobilized circumferentially to a level typically just above the divided azygos vein.
●Once the intrathoracic esophagus has been adequately mobilized, the proximal esophagus is divided with an Endo GIA stapler above the level of the azygos vein. The proximal extent of dissection is dependent on the indication for esophagectomy; however, the planned level of the intrathoracic anastomosis is always above the level of the azygos vein.
●Next, the specimen and gastric conduit are carefully brought into the thorax through the hiatus with gentle traction. The surgical team must be vigilant in maintaining proper orientation of the conduit to prevent torsion. The staple line of the gastric conduit should be facing laterally (toward the ceiling of the operating room). The gastric conduit staple line is then completed, and the esophagogastric specimen is removed through the low anterior access incision. The proximal and distal margins are sent for pathology.
Anastomosis — Once adequate margins are confirmed by pathology, the esophagogastric anastomosis is constructed. We utilize the OrVil 25 mm anvil and the EEA XL circular stapler (25 mm with 4.8 mm staples) to complete the intrathoracic anastomosis [2,5,13].
●The OrVil EEA anvil-orogastric tube device is passed transorally by the anesthesiologist until the surgeons are able to visualize it abutting the esophageal staple line. A small esophagotomy is made, and the attached orogastric tube is retrieved. With careful coordination between the surgeon and anesthesiologist, the OrVil is seated within the proximal esophageal stump. A pursestring may be used to cinch up the esophagotomy around the OrVil if necessary.
●The gastric conduit should be brought further into the chest. The conduit should be assessed for length to estimate the location of the anastomosis and aim to place the anastomosis in an area that appears well perfused. The anastomosis should be tension free, but a redundant conduit should be avoided as it tends to lead to functional and emptying issues in the patient's postoperative course.
●A gastrotomy is made at the tip of the conduit through which the EEA stapler is placed into the conduit and positioned for the anastomosis (figure 7). The stapler spike should be brought out through the greater curve of the stomach, again maintaining appropriate orientation of the conduit to prevent twisting. The stapler is coupled with the anvil and fired, and "donuts" from the anvil should be assessed for completeness. We recommend reinforcing the anastomotic staple line with circumferential silk sutures.
●Once the anastomosis has been created, the excess gastric fundus should be trimmed using an Endo GIA stapler, which also closes the gastrotomy (figure 8). This staple line should not be too close to the anastomotic staple line, or else the small bridge of interposing stomach will be at risk for subsequent ischemia. We aim to have approximately 2 cm of tissue between these staple lines as shown (figure 9). An air-leak test utilizing an endoscope is performed at this time.
●Finally, the anastomosis is wrapped with the omental flap that was preserved in the abdomen and brought to the chest.
●We tend to leave two drains within the pleural cavity: a proper chest tube within the pleural space as well as a soft round Blake drain medial to the gastric conduit.
MINIMALLY INVASIVE THREE-FIELD MCKEOWN ESOPHAGECTOMY — In this version of minimally invasive esophagectomy, the thoracoscopic phase of the operation described above is completed first with the patient in the left lateral decubitus position with a double-lumen endotracheal tube [14]. Esophageal mobilization is completed up to the thoracic inlet proximally and to the hiatus distally. (See 'Thoracic phase' above.)
Once the intrathoracic phase of the operation has been completed, the patient is placed in supine position, and the double-lumen tube is exchanged for a single-lumen tube. The abdominal phase of the procedure is completed as described above. (See 'Abdominal phase' above.)
The specimen is extracted from a left neck incision, and the conduit is also brought up to the neck through this incision (figure 10). A stapled or hand-sewn anastomosis is completed through the left neck incision [15].
MINIMALLY INVASIVE TRANSHIATAL ESOPHAGECTOMY — This version of minimally invasive esophagectomy begins laparoscopically similarly to the abdominal phase of the Ivor Lewis esophagectomy described above. (See 'Abdominal phase' above.)
The esophageal dissection is continued through the hiatus under direct visualization to the level of the left mainstem bronchus [14]. If further mediastinal dissection is required, a hand port can be placed in the upper abdomen to facilitate adequate esophageal mobilization [2]. The specimen is again brought to a left neck incision where the anastomosis is created (hand sewn or stapled).
OUTCOMES — Early reports indicated the safety and feasibility of minimally invasive esophagectomy [16-21]. More contemporary meta-analyses comparing minimally invasive esophagectomy with open esophagectomy have concluded the decreased frequency of complications and in-hospital mortality occurring in minimally invasive compared with open esophagectomy, usually due to a decrease in pulmonary complications [20,21].
As with any complex surgical procedure, a learning curve is present in adopting minimally invasive esophagectomy. A prospective study investigating the anastomotic leaks following minimally invasive esophagectomy noted a plateau was reached following 119 procedures [22]. Furthermore, increased experience was related to decreased duration of surgery. A retrospective study indicated decreased perioperative morbidity and mortality with increased surgeon experience. In this study, the learning curve for minimally invasive esophagectomy was estimated to be 25 to 30 procedures [23].
Oncologic outcomes of minimally invasive esophagectomy are discussed in detail in another topic. (See "Surgical management of resectable esophageal and esophagogastric junction cancers", section on 'Minimally invasive approaches'.)
COMPLICATIONS — Although the choice of minimally invasive esophagectomy techniques is largely determined by surgeon preference, and partly dependent on patient and tumor factors, the choice of techniques can have a direct impact on patients' postoperative morbidities.
Generally speaking, a cervical anastomosis is associated with a greater risk of anastomotic leak, stricture, recurrent laryngeal nerve injury, and swallowing dysfunction, whereas an intrathoracic anastomosis can be associated with more cardiopulmonary complications and direr consequences when the anastomosis leaks [2].
Specific perioperative complications related to esophageal resection are reviewed separately. (See "Complications of esophageal resection".)
SUMMARY AND RECOMMENDATIONS
●Esophagectomy consists of esophagogastric mobilization with or without lymphadenectomy, conduit construction, resection, and anastomosis. Each component can be performed open or with minimally invasive techniques such as laparoscopy, thoracoscopy, mediastinoscopy, and robotic approaches. (See 'Introduction' above.)
●The technique of totally minimally invasive Ivor Lewis esophagectomy with intrathoracic anastomosis is described and illustrated in detail. (See 'Abdominal phase' above and 'Thoracic phase' above.)
●Three-field McKeown esophagectomy and transhiatal esophagectomy can also be performed using minimally invasive techniques. (See 'Minimally invasive three-field McKeown esophagectomy' above and 'Minimally invasive transhiatal esophagectomy' above.)
●A growing body of literature has associated minimally invasive techniques of esophagectomy with a lower rate of perioperative complications (especially pulmonary complications) compared with open esophagectomy. Oncologic outcomes of minimally invasive esophagectomy are discussed elsewhere. (See 'Outcomes' above.)
●The choice of minimally invasive esophagectomy techniques is largely determined by surgeon preference and partly dependent upon patient and tumor factors; the choice of techniques can have a direct impact on patients' postoperative morbidities. (See 'Complications' above.)
