Chapter 14

Transhiatal esophagectomy was popularized by Orringer in the late 1970s as a less invasive approach to esophagectomy.1,2 Although this approach carries potential benefits, including fewer pulmonary complications, possibly owing to the avoidance of a thoracotomy, it has been endorsed primarily by nonthoracic general surgeons who perform esophagectomy. The main limitations are the inability to perform an extensive lymph node dissection and the potential risk of injury to the great vessels and main airways with tumors of grade T3 or greater.3,4 We describe herein our current technique for transhiatal esophagectomy, which includes minor modifications to the original Orringer technique.

Transhiatal esophagectomy is performed via an upper midline laparotomy incision and a left neck incision. Unlike the left transthoracic approach, the transhiatal approach offers excellent exposure of the abdominal cavity.5–7 A generous Kocher maneuver can be performed, allowing the pylorus to extend almost to the hiatus. This helps to provide the length needed to pull the stomach into the neck. A pyloromyotomy or pyloroplasty can be performed easily, helping to decrease symptomatic gastric stasis postoperatively. There is ample exposure to allow a feeding jejunostomy to be created, aiding in postoperative nutrition.

The lack of a thoracotomy incision in transhiatal esophagectomy has potential advantages. The incisional pain associated with thoracotomy is avoided. The need for one-lung anesthesia is obviated. A chest tube is usually not required. These factors may be of particular importance in patients with severe chronic obstructive pulmonary disease, poor pulmonary function, or both. On the other hand, the lack of exposure of the mediastinum limits the surgeon's ability to fully assess that portion of the surgical field and to perform radical resection.4 Moreover, the surgeon's hand dissects bluntly behind the heart for a significant length of time during the procedure, making this approach more risky intraoperatively in patients with compromised cardiac function.

The left neck incision used in transhiatal esophagectomy affords excellent exposure of the cervical esophagus. The esophageal resection can be extended fairly high in the neck, encompassing even high esophageal lesions adequately. The length of gastric conduit required to reach the neck results in higher leak and stricture rates compared with intrathoracic anastomoses. In the event of a cervical esophagogastric anastomotic leak, however, satisfactory drainage is easily obtained by reopening the neck wound, making the clinical consequences less severe than those of an intrathoracic anastomotic leak. Although methods have been described for performing a stapled cervical esophagogastric anastomosis, the lack of an ideally suited stapling device makes these techniques somewhat awkward. The anastomosis is usually hand sewn and may take more time to complete than a stapled anastomosis.

The left recurrent laryngeal nerve is at risk in transhiatal esophagectomy, and left vocal cord palsy is a well-recognized complication. In addition to increasing the risk of aspiration owing to incoordination of swallowing, vocal cord palsy may reduce the effectiveness of coughing and compromise tracheobronchial toilet. ...

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