An additional 10-mm port is placed in the right lower quadrant to facilitate jejunostomy tube placement. The transverse colon is retracted cephalad using a grasper applied to the adjacent fatty epiploicae, and the ligament of Treitz is identified. Approximately 40 cm from the ligament of Treitz, a loop of jejunum is attached to the anterior abdominal wall in the left lower quadrant using an Endo Stitch. A 10-Fr laparoscopic feeding jejunostomy tube is inserted into the jejunum percutaneously using the Seldinger technique. The guidewire is threaded into the small bowel, followed by the catheter, to a distance of approximately 20 cm. The jejunum is further tacked to the anterior abdominal wall using three additional endosutures as well as a single suture approximately 3 cm distal to the entrance site to prevent torsion. The feeding catheter is secured on the skin, and 10 mL of air is injected rapidly into the small bowel to test for patency and confirm intraluminal placement. If any doubts exist as to true luminal placement, an on-the-table Gastrografin study of the jejunostomy tube should be performed.
The patient is placed in the left lateral decubitus position. The right lung is isolated. Four ports are used to access the right chest (Fig. 15-6). A 10-mm camera port is inserted in the anterior axillary line at the eighth interspace. An additional 10-mm port is placed approximately 2 cm posterior to the posterior axillary line in the eighth or ninth interspace. This is the main dissection port for the harmonic scalpel (Ethicon). A 10-mm port is placed in the fourth interspace along the anterior axillary line. A fan retractor is placed through this port to provide retraction of the lung. Finally, a 5-mm port is placed below the scapular tip. A fifth 5-mm port can be placed at the sixth rib, at the anterior axillary line, for suction by the assistant. The addition of insufflation can depress the diaphragm to give better visualization of the hiatus. Alternatively, an Endo Stitch can be placed in the central tendon of the right diaphragm and brought out percutaneously through the lower chest wall near the costal margin using the Endo-Close device (Covidien, Norwalk, CT). Downward traction on this stitch pulls the diaphragm inferiorly and allows better visualization of the lower esophagus and hiatus.
Dissection is begun by taking down the inferior pulmonary ligament (Fig. 15-7). The mediastinal pleura is dissected anteriorly along the plane between the edge of the lung and the esophagus and is resected with the specimen up to the azygos vein. The subcarinal lymph nodes are taken en bloc with the esophagus. Care is exercised to avoid injury to the posterior membrane of the right mainstem bronchus, carina, and trachea. Dissection is carried up to the azygos vein, and the vein is divided with an Endo-GIA stapler (Covidien, Norwalk, CT).
The mediastinal pleura is also divided inferiorly near the hiatus (Fig. 15-7) Tributaries from the thoracic duct to the esophagus are at risk for subsequent leak. Liberal use of endoclips here will minimize the chances of a postoperative chylous leak. Aortoesophageal attachments are also isolated, clipped, and divided. All surrounding soft tissue is taken with the esophagus, including the lymph node packets. Once the dissection is carried up to the divided azygos vein, the vagus nerve is divided, and the dissection is now performed close to the esophagus. By dissecting the surrounding tissue away from the esophagus, traction on the vagus nerve is minimized, and the risk of recurrent nerve injury is decreased. Care is taken to preserve the mediastinal pleura above the azygos vein. This precaution is an aid to maintaining the gastric tube in the mediastinum and seals the surrounding tissue to minimize leakage of any cervical drainage into the chest.
Periesophageal dissection can be taken all the way up to the thoracic inlet. Once the esophagus is mobilized, the specimen and the gastric conduit are brought into the field with gentle retraction of the esophagus. The suture is divided separating the specimen and gastric conduit. Once the esophagus is fully mobilized up to the upper chest cavity, the esophagus is sharply divided with endoshears, dividing the proximal esophagus and separating the specimen. The posterior inferior dissection port is increased by 2 cm and fitted with a wound protector (Alexis, Applied Medical). The specimen is removed through the wound.
The open esophagus is gently dilated with a balloon and the anvil of an end-to-end anastomosis (EEA) stapler is placed within the lumen. The edges of the esophagus are then suture closed with two rows of purse-string suture. Use of an endosuture (Covidien) or free-hand suture is generally required to form a snug fit around the anvil. The gastric conduit is brought up into the field, and the proximal end is divided to open the conduit. The handle of the EEA stapler is placed through the posterior incision and into the open end of the conduit. The spike is brought out along the greater curvature at a site that is distal to the opening and well perfused (Fig. 15-8). This spike is attached to the anvil, reapproximated, and fired to form the anastomosis. The EEA stapler is gently removed. Once an NG tube is placed, the open end of the gastric conduit can be resected flush, in line with the body of the conduit with the Endo-GIA stapler, closing the opening and leaving generally an in-line conduit in the esophageal bed (Fig. 15-9). If adequate omentum has been brought up to the chest, it can be used to buttress the anastomosis and staple lines. The chest is washed with multiple liters of saline. Chest tubes are placed, including a Blake drain near the conduit. The chest is closed, completing the reconstruction.
Creation of the esophagogastric anastomosis.
The gastrotomy is closed with an Endo-GIA stapler.
Three-Hole Approach and Cervical Anastomosis
For a 3-hole modified McKeown approach, the dissection is started in the right chest with the patient in the left lateral decubitus position. Full mobilization is performed using similar port placement as described for the thoracoscopic phase of the Ivor Lewis MIE. In this case, however, the dissection of the mediastinal pleura is continued up to the thoracic inlet. A Penrose drain is wrapped around the esophagus for later retrieval in the neck. The patient is placed supine and the stomach mobilized as described above. The phrenoesophageal ligament is dissected last, as entrance here can evacuate the abdominal insufflation into the right chest and out the chest tube. Hence, keeping this area intact until one is ready to bring the conduit up to the neck will keep the abdomen insufflated.
A horizontal incision is made along a cervical crease above the sternal notch and extending to the left. Dissection is carried down, and platysmal flaps are developed. Dissection is continued along the anterior border of the sternocleidomastoid muscle. The omohyoid muscle is divided, and gentle dissection is continued down to the prevertebral fascia. The cervical esophagus is gently retracted medially with a peanut dissector. Careful dissection performed inferiorly should open into the thoracic inlet. The Penrose drain left in the thoracic inlet at the end of the thoracoscopic portion of the surgery should be readily encountered in the neck and retracted out through the cervical wound. Once the cervical esophagus is bluntly dissected free, delivery of the specimen out the neck incision along with the attached gastric conduit is possible. An assistant observes the orientation of the gastric tube with the laparoscope as it is guided up through the hiatus. Care must be taken to preserve proper orientation and prevent spiraling or tension at the hiatus. Once the gastric tube is delivered into the neck, the two endosutures are divided. The proximal gastric tube is assessed for viability. The proximal cervical esophagus is mobilized. An auto–purse-string device (Covidien, Norwalk, CT) is applied 2 to 3 cm distal to the cricopharyngeus, and the esophagus is divided. A 25-mm EEA stapler is used to perform the anastomosis. The anvil is placed in the cervical esophagus, and the purse string is tied. The proximal gastric tube tip is opened, and the EEA stapler is inserted and directed posteriorly between the staple line and the line of the short gastric arteries. Usually, the gastric tube is sufficiently long to permit the anvil to exit the gastric tube 6 to 8 cm distally. Once the anastomosis is complete, a nasogastric tube is guided under direct vision. The gastrotomy opening is closed by stapling off the distal 5 to 6 cm of the proximal gastric tube with an Endo-GIA stapler.
Attention is directed back into the abdomen. Graspers are applied to the antral area, and gentle downward traction is applied until the cervical anastomosis dips into the neck incision. This maneuver ensures the absence of redundant gastric tube above the hiatus that may have been pulled up during creation of the neck anastomosis. The gastric tube is tacked to the hiatus to prevent future herniation (Fig. 15-10). Care must be taken to avoid injury to the vascular supply. We generally apply three sutures, one from the greater-curve side to the left crus, one from the lesser-curve side to the right crus, and one on the anterior gastric tube to the central edge of the diaphragmatic hiatus. The cervical anastomosis is irrigated, and the skin is only loosely approximated with one or two staples. In our experience, multilayer suture closure of the cervical incision may lead to downward tracking of an anastomotic leak, should one occur.