The technique of minimally invasive esophagectomy (MIE) can be applied to almost any condition for which resection is indicated. Current indications include neoplasms, end-stage achalasia, esophageal perforation, Barrett esophagus with high-grade dysplasia, and complications of severe gastroesophageal reflux disease (GERD), especially undilatable strictures. Although initial experience with MIE primarily involved patients with Barrett esophagus and high-grade dysplasia, it has evolved to include most patients with resectable malignant lesions, including those with nodal involvement and patients who have undergone prior neoadjuvant chemoradiation therapy. Although there are no absolute contraindications for MIE, resection of large bulky tumors, reoperative upper abdominal or thoracic operations, and the need for colon interposition would commonly necessitate an open approach. Occasionally, a patient may be a candidate for a “hybrid” procedure: a patient with previous mediastinitis may need a thoracotomy and laparoscopy, or a patient with multiple previous abdominal operations may need a laparotomy but has no contraindication to thoracoscopy. There are many variations of MIE, but three approaches predominate: (1) thoracoscopic and laparoscopic dissections with cervical anastomosis (three-field esophagectomy), (2) laparoscopic and thoracoscopic dissections with intrathoracic anastomosis (Ivor-Lewis technique), and (3) laparoscopic transhiatal technique with cervical anastomosis (inversion esophagectomy) (Figure 1). In this chapter we describe the first two operations; laparoscopic transhiatal esophagectomy is described in Chapter 22.
Patients undergoing MIE 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 is 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.