Transhiatal esophagectomy (THE) is indicated when two- or three-field transthoracic esophagectomy is unnecessary or when patient condition suggests that thoracotomy is risky. In patients with very early stage esophageal cancer, in which extended lymph node dissection is not necessary, i.e., Barrett esophagus with high grade dysplasia; or T1a esophageal cancer, THE is indicated. The frequency of lymph node (LN) metastases with T1b cancer warrants two- or three-field esophagectomy in the otherwise healthy patient with esophageal cancer. Lower esophageal adenocarcinoma or gastroesophageal (GE) junction cancer of more advanced stage can also be addressed with THE in the patient at excessive risk of complication after thoracotomy. Advanced cancers of the mid-esophagus should not be addressed with THE, as the midesophageal dissection is essentially blind, and therefore unsafe with THE. Benign indications for esophagectomy may be addressed with THE, with one caveat. The megaesophagus associated with end-stage achalasia is extremely vascular. Attempts to “strip” this esophagus from its mediastinal bed may result in large-volume bleeding. Direct transthoracic dissection (open or with thoracoscopy) is advisable in this setting (Figure 1).
Patients undergoing minimally invasive esophagectomy must be carefully evaluated prior to surgery. The evaluation of a suspected malignancy includes a thorough staging workup. This should include computed tomography (CT) of the chest, abdomen, and pelvis; an esophagogastroduodenoscopy (EGD); a bronchoscopy for mid- to upper esophageal tumors; an endoscopic ultrasound; and a combined CT and positron emission tomography (PET) scan to provide clinical staging for all locally advanced tumors. Occasionally laparoscopic and/or thoracoscopic staging is needed to confirm or rule out extraesophageal metastases, but this is not routinely necessary. Cardiopulmonary risk stratification and optimization is pursued for all patients. Functional testing includes stair climbing and/or a 6-minute walk. Physiologic evaluation includes pulmonary function tests, an echocardiogram, and a stress test. Patients are placed on an exercise program, and smoking cessation is mandatory. In addition, all patients meet with a dietician preoperatively to promote nutritional optimization. In patients who are diabetic, tight control of serum blood glucose is achieved several weeks prior to surgery. Screening colonoscopy and visceral angiography are obtained in selected cases where there is a concern that the stomach will not be an adequate conduit for reconstruction. If there is any concern about other comorbidities, appropriate consultation is obtained preoperatively. Patients at high risk for arrhythmia or myocardial ischemia are placed on perioperative beta blockers. Anticoagulants, nonsteroidal anti-inflammatory agents, and antiplatelet agents are discontinued approximately 7 days prior to surgery if possible. Other preoperative medications are continued until the morning of surgery.
ANESTHESIA AND PATIENT POSITIONING
Prophylactic antibiotics are administered and antiembolism pneumatic stockings are placed before the induction of general anesthesia. Preoperatively, cervical range of motion should be evaluated to gauge the patient’s ability to tolerate varying degrees of extension ...