The transhiatal esophagectomy involves four phases: abdominal, cervical, mediastinal, and anastomosis. With the patient supine, the left arm is tucked leaving the right arm out at 90 degrees for venous and arterial access. Though not mandatory, a central venous catheter, if required, is placed in the right internal jugular vein. All bony prominences are padded, and the head is extended, turned to the right, and supported on a soft O-ring. The skin is prepped from the left ear to the pubis and laterally to both midaxillary lines.
The abdominal phase is initiated through an upper midline incision from the xiphoid process to the umbilicus (Fig. 87-1). The right and left costal margins are retracted cephalad toward the ipsilateral shoulders with a self-retaining table-fixed retractor. The ligamentum teres, falciform, and triangular ligaments of the liver are divided, facilitating retraction of the left lateral segment upward and to the right. The stomach is then assessed for its suitability as a conduit. The greater omentum is divided along the greater curvature of the stomach maintaining a safe distance inferior to the right gastroepiploic vessels to avoid injury to the primary blood supply to the conduit. The left gastroepiploic and short gastric vessels are identified and are ligated just outside the border of the greater curvature. Care should be taken to avoid unnecessary traction on the stomach.
Patient is positioned supine with the left arm tucked, head extended and turned to the right with upper midline and left cervical incisions. (Copyright 2011, used with permission from CTSNet (www.ctsnet.org). All rights reserved.)
The gastrohepatic omentum is divided along the liver edge in the avascular plane overlying the caudate lobe. A replaced left hepatic artery arising from the left gastric artery should be preserved when encountered in this area. Careful dissection inferiorly along the lesser curvature is performed to the right gastric vessels, which in almost all instances can be preserved and provides added blood supply to the gastric tube. The remnant gastrocolic omentum is freed from the greater curvature of the stomach with attention to preserving the right gastroepiploic vessels up to its origin at the gastroduodenal artery. A Kocher maneuver exposes the border of the superior mesenteric vessels. The hepatic flexure is taken down to allow full mobilization of the pylorus to the esophageal hiatus. A pyloromyotomy (or pyloroplasty) is routinely performed to limit gastric stasis as a consequence of vagal disruption.
Prior to division of the left gastric vessels, a common hepatic, celiac-axis, proximal splenic, and left gastric lymphadenectomy is performed with all nodal tissue swept up with the specimen (Fig. 87-2). With the stomach retracted anteriorly and superiorly, the left gastric artery and the coronary vein are ligated at their origins. All remaining posterior gastric vessels are divided and all nodal tissue around the crus of the diaphragm and the aorta is dissected. Once this is completed, the peritoneum overlying the esophageal hiatus is incised and the gastroesophageal junction is encircled with an umbilical tape, which is secured and used for traction during the mediastinal mobilization. The esophageal hiatus should be widened by dividing the crus with electrocautery after ligating the inferior phrenic vein. This creates excellent exposure of the inferior mediastinum that extends superiorly to the carina. The initial dissection of the distal esophagus is performed from pleura to pleura laterally and from pericardium to aorta in the anterior/posterior plane using alternating traction and counter traction, electrocautery, and liberal use of large hemoclips to incorporate the periesophageal soft tissue. Continual assessment of whether the esophagus is fixed to the adjacent spine, prevertebral fascia, aorta, pleura, or pericardium is carried out during the dissection until the carina is reached. If the pleura are traversed, a chest tube is inserted. Hemostasis is easily achieved with surgical packing when neccesary.
The cervical phase is initiated with a 6- to 7-cm incision along the anterior border of the left sternocleidomastoid muscle starting just above the suprasternal notch. The platysma is divided, the sternocleidomastoid muscle is retracted laterally, and the central tendon of the omohyoid muscle is incised. The carotid sheath and its contents are retracted laterally and the middle thyroid vein is divided to allow access to the prevertebral space. A blunt self-retaining retractor is utilized to retract the sternocleidomastoid muscle, carotid artery, and internal jugular vein laterally and retract the trachea and thyroid medially. With care to avoid injury to the recurrent laryngeal nerve in the tracheoesophageal groove, the cervical esophagus is encircled with a Penrose drain using delicate blunt and sharp dissection on the adventitia of the esophagus . Using upward and superior traction with the Penrose drain, careful blunt dissection is carried out within the superior mediastinum to the level of the innominate artery (Fig. 87-3).
With a penrose drain for traction, the cervical esophageal is gently dissected toward the superior mediastinum. (Copyright 2011, used with permission from CTSNet (www.ctsnet.org). All rights reserved.)
The mediastinal phase proceeds with downward traction on the umbilical tape encircling the esophagogastric junction, while the opposite hand is placed through the diaphragmatic hiatus into the posterior mediastinum. The posterior attachments of the esophagus to the aorta are bluntly freed until a finger extending to the posterior mediastinum through the cervical incision can be palpated by the hand extending up from the diaphragmatic hiatus (Fig. 87-4). The anterior attachments are then freed by manually hugging the anterior wall of the esophagus, sliding under the carina, and carefully freeing the esophagus from the membranous trachea. During the mediastinal dissection, care must be taken to avoid creating pressure anteriorly on the heart that can result in prolonged hypotension. If hypotension does occur, it is usually responsive to volume resuscitation. Next, using a “sweetheart” retractor, the inferior lateral attachments can be easily visualized and are ligated and divided between clips. The superior attachments including small vagal branches are easily detached using blunt manual dissection. After complete mobilization of the entire intrathoracic esophagus, the cervical and upper mediastinal esophagus is mobilized into the cervical wound. After the nasogastric tube is withdrawn, the esophagus is divided using a GIA stapler, which concomitantly secures a long Penrose drain (marked along one plane to help with orientation when brought through the mediastinum) to the distal divided esophagus. The stomach and the distal esophagus is brought out through the abdominal wound with the Penrose drain drawn through the posterior mediastinum to be used to guide the gastric tube to the cervical incision. Selecting the most superior point on the stomach, a gastric tube is formed using multiple firings of the GIA stapler ensuring preservation of the greater curvature and its blood supply (Fig. 87-5). The lesser curvature angle is progressively unfolded during stapled division of the stomach to create the maximal length for the gastric conduit. The final specimen will include the esophagus with the tumor and a portion of the fundus, cardia, and lesser curvature, which should secure an adequate distal margin. The Penrose drain is then sutured to the posterior aspect of the gastric conduit with silk sutures to orient the conduit (lesser curvature suture is long and greater curvature suture is short) and maintain the proper orientation during transposition. The gastric conduit is gently pushed up through the diaphragmatic hiatus manually with only slight traction from the Penrose drain through the cervical incision to avoid tearing. Approximately 6 to 8 cm of the stomach wall should be easily mobilized onto the cervical field. After assurance that there is no twisting of the conduit, the Penrose drain and orienting sutures are cut.
Completion of the posterior mediastinal dissection. (Copyright 2011, used with permission from CTSNet (www.ctsnet.org). All rights reserved.)
Stapled technique for the esophagogastric anastomosis using a 25- or 28-mm EEA stapler.
An automatic purse-string suture applier is placed on the cervical esophagus removing the excess tissue. A 25- or 28-mm EEA circular stapling device anvil is placed in the cervical esophagus and secured with the purse-string suture. Using an anterior gastrotomy, the shaft of the EEA stapler is positioned through the gastric conduit, and the trocar is brought through the proximal, posterior gastric wall. The circular stapling device is then engaged on the anvil and deployed completing the esophagogastrostomy (Fig. 87-6). The proximal “donut” of tissue is sent to pathology as the final proximal margin. After the anastomosis is inspected for hemostasis and a nasogastric tube is passed under direct visualization through the anastomosis to lie in the gastric antrum, the excess gastric tissue proximal to the anastomosis including the anterior gastrotomy is excised with a linear stapler (TA-60 with 4.8 mm staples). The integrity of the anastomosis is assessed using an endoscope to insufflate the conduit while submerged under saline to detect any air leaks that would require reinforcement with 3-0 silk sutures. The gastric tube is once again inspected for viability and then secured to the surrounding tissue using two 3-0 silk sutures (excluding the prevertebral fascia that could predispose to abscess formation). The platysma is reapproximated and the cervical incision is closed using skin staples. Drains are unnecessary.
Prior to closure of the abdominal incision, the stomach is secured to the hiatus with two 3-0 silk sutures. A needle catheter feeding jejunostomy is then placed to complete the procedure.