15: Minimally Invasive Esophagectomy

Introduction

First described in ad 160 by Galen, the esophagus has proved to be a challenging organ to understand and manipulate. Its complex physiology and treacherous location in the posterior mediastinum precluded surgical manipulation until the 20th century. The first thoracic esophageal resection was described by Torek in 1915.¹ He illustrated a resection of the midesophagus with an extra-anatomic reconstruction. Although he described only one survivor, this event heralded the beginning of esophageal surgery. For the remainder of this century and into the next, surgeons have endeavored to improve the technique and outcomes of this thoracic specialty.

Orringer and Sloan² popularized a transhiatal approach to esophageal resection and a gastric tube reconstruction. McKeown³ described a three-field approach requiring a thoracotomy to perform the majority of the esophageal dissection, followed by a laparotomy for the gastric mobilization, and finally, a cervical incision for anastomosis. Variations in approaches and reconstructions have provided today's surgeons with a large armament of techniques and fodder for debate over the ideal approach.

Open surgical procedures remain the standard of care for esophageal resections in most medical centers. However, the morbidity and mortality associated with open procedures and the diseases for which they are required still reveal the need for further improvement. A 10-year review of the esophagectomy experience within the Veterans' Affairs hospital system revealed a morbidity of 50% and a mortality of 10%.⁴ Birkmeyer et al.,⁵ in a recent analysis of a national Medicare database, revealed that the mortality rates from esophagectomy in the United States ranged from 8% in high-volume centers to 23% in low-volume centers.

Beginnings of Mie

The advent of laparoscopy and thoracoscopy in the 1980s opened the door to the possibility of a minimally invasive approach to esophageal surgery. Initial experience with laparoscopic Nissen fundoplications formed the basis of the early surgical experience, followed by the use of laparoscopic and thoracoscopic staging of lymph nodes. Collard et al.⁶ were the first to describe a thoracoscopic technique for esophageal dissection. Although multiple reports of laparoscopic-assisted esophagectomies followed, it was not until DePaula et al. published their initial experience in 1996 that a totally laparoscopic esophagectomy was documented.⁷ Although this report detailed a laparoscopic transhiatal approach,^8-10 our center and others have used primarily a combined thoracoscopic and laparoscopic approach.^11-14 The thoracoscopic approach affords better visualization of the periesophageal structures, especially near the main airways and subcarinal areas. It is also less affected by patient height and body habitus and, in our experience, improves nodal dissection and overall visualization compared with the totally laparoscopic method. In 2000, Nguyen et al.¹⁵ compared the minimally invasive approach with open transthoracic and transhiatal esophagectomy. The minimally invasive approach documented shorter operative times, less blood loss, and shorter stays in the intensive care unit with no increase in morbidity compared with the ...