16: Transhiatal Esophagectomy

Introduction

Transhiatal esophagectomy was popularized by Orringer in the late 1970s as a less invasive approach to esophagectomy.^1,2 This approach avoids thoracotomy and has been endorsed primarily by nonthoracic general surgeons who perform esophagectomy. For trained thoracic surgeons, the main drawbacks of this approach are the inability to perform an extensive lymph node dissection and the 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.

Comparisons of transhiatal versus transthoracic esophagectomy published in the last decade have included retrospective studies,^5,6 prospective studies,⁷ randomized controlled studies,⁸ and meta-analyses.⁹ The published evidence suggests that transhiatal esophagectomy is associated with a reduced risk of pulmonary complications and in-hospital mortality as well as a shortened length of hospital stay, but an increased risk of anastomotic leakage and postoperative vocal cord paralysis. Although there is no clear difference in overall long-term survival, there is an apparent trend toward improved 5-year survival with transthoracic esophagectomy in patients with a limited number of involved lymph nodes.¹⁰ Published data comparing transhiatal esophagectomy with totally minimally invasive esophagectomy is rather limited.^11,12

Technical Principles

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.^13-15 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.¹⁶

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 ...