Minimally Invasive Ivor Lewis Esophagectomy

1. Anesthesia

1. General anesthesia. Single lumen endotracheal tube for the abdominal portion, switching to a double lumen endotracheal tube for the chest.
2. An epidural is not used for an MIE. This simplifies the postoperative care with minimal use of vasopressor agents and limiting fluid requirements.
3. Rib blocks of 0.5% Marcaine are given at the conclusion of the chest portion.

2. Patient Positioning

1. For the abdominal portion, the patient is supine and positioned to the right side of the operating table to allow for the liver retractor to optimally raise the left lobe of the liver.
2. For the chest portion of the procedure, a double lumen endotracheal tube is placed. The patient is placed in the left lateral decubitus position with the break of the table at the xiphoid process.

3. Endoscopy

1. An endoscopy is performed before all esophageal resections.
2. This allows for accurate assessment of tumor location, and if present the length of Barrett’s esophagus to be removed.
3. The stomach is thoroughly inspected and the gastroesophageal junction assessed for tumor extension into the cardia of the stomach.

4. Laparoscopic Port Placement

1. A total of six laparoscopic ports are used for the abdominal portion of the case.
2. Four ports are placed across the upper abdomen. Two 5/12mm ports are placed at the midclavicular line, 2/3rds of the way from the xiphoid process to the umbilicus. Two 5mm ports are placed at the costal margins after the abdomen has been insufflated. A final 5mm port is placed at the low right costal margin for the liver retractor.
3. The sixth port is placed in the right lower quadrant 5-7 cm below the right mid clavicular port. If a laparoscopic jejunostomy is to be performed, this is a 5/12mm port which allows tacking of the jejunostomy. If no jejunostomy, it is a 5mm port for a third grasper used in the creation of the gastric conduit.

5. Abdomen

1. On entering the abdomen, the liver and peritoneal surfaces are inspected for occult metastatic disease.
2. The gastrohepatic omentum is opened and the right crus exposed.
3. The right crus is grasped and reflected toward the liver allowing for the development of a plane along the esophagus.
4. Attempts are made to stay out of the chest during this portion of the operation as not to cause a pneumothorax potentially leading to hypotension.
5. The right crus dissection is carried inferiorly toward the convergence of the right and left crus and over the top of the esophagus, dividing the phrenoesopageal ligament.
6. With the esophagus mobilized, dissection begins on the left gastric artery and vein from the lesser curve side of the stomach.
7. The peritoneum around the left gastric artery is opened and celiac nodes are swept up. The artery and vein are dissected cleanly to their bases. Critical to this portion of the dissection is the previous mobilization of the right crus above the artery and vein.
8. The left gastric artery and vein are not divided at this point as to not devascularize the fundus of the stomach further while the greater curve dissection is carried out.
9. Moving to the greater curve, the gastrocolic omentum is splayed out to demonstrate the arcade – grasping the stomach and the omentum and placing it on slight stretch). A window into the lesser sac is developed by identifying the thin plane in the omentum. Critical is to not be too close to the right gastroepiploic artery, but equally as important is not to get “lost” in the greater omentum.
10. Carry the dissection inferiorly toward the duodenum.
11. Dissection of the short gastric begins from a window is identified where the epiploic artery ends and the short gastric arteries begin.
12. When this window is identified, the dissection moves onto the stomach and the short gastrics are taken.
13. With the greater curve dissection complete, the stomach is rotated up exposing the posterior side of the stomach and retrogastric attachments are taken down.
14. A sixth port is placed a handsbreath directly below the right 5/12mm midclavicular port. This is either a 5 mm port or a 5/12mm port if a laparoscopic jejunostomy is to be created.
15. The gastric tube is created using three graspers. The surgical assistant’s grasper is placed high on the fundus. A second grasper is placed through the right lower quadrant port along the greater curve, tensioning the great curve to keep the conduit straight and gain additional conduit length. The surgeon’s grasper is placed on the lesser curve.
16. The first stapler load is across the gastrohepatic omentum on the lesser curve. This is typically a vascular load to control lesser curve vessels.
17. Thick tissue staplers are used on the stomach to create a gastric conduit 5-6 cm in width.
18. With the gastric tube created, the esophagus at the hiatus is aggressively dissected into the mediastinum as far as can be safely performed.
19. The gastric tube is then tacked to the specimen with a mattress stitch that is carefully placed as to maintain proper orientation and not twist the gastric conduit.
20. Liver retractor is removed and ports are closed.

6. Chest

1. The patient is positioned in the left lateral decubitus position.
2. A total of 5 thoracoscopic ports are placed in the right chest. Two posteriorly over the 6th and 8th ribs are for the operating surgeon (Harmonic scalpel and grasper).
3. Anteriorly, the camera is placed inferiorly over the 9th interspace and a fourth port anteriorly at the 5th interspace for a lung fan retractor. Finally, a small fifth port is placed between the two anterior ports for a suction irrigator.
4. A long endostitch is placed in the central tendon of the diaphragm. A disposable Carter-Thompson device is used to grasp the stitch and pull the diaphragm inferiorly.
5. The chest portion begins by opening the pleura along the posterior hilum. This dissection is carried to the azygos vein where it is divided it with a vascular load of the stapler.
6. With the azygos vein divided, dissection begins the chest wall opening the pleura and working circumferentially around the esophagus. Care is taken to stay slightly off the chest wall as to avoid the thoracic duct.
7. With the esophagus dissected to the level of the azygous vein, the specimen and attached conduit are brought into the chest. The staple line of the conduit should be facing upward.
8. Dissection is completed circumferentially above the azygous vein.
9. All periesophageal nodes and subcarinal lymph nodes are dissected and completely removed.
10. The inferior posterior port is enlarged to 6 cm and a wound protector is placed. This will allow for removal of the specimen and placement of the EEA stapler.
11. The esophagus is transected approximately 2 cm below the highest level of dissection. This will allow for room for anvil placement.
12. The specimen is removed through the wound protector and the anvil of the EEA stapler placed in the proximal esophagus.
13. The anvil is secured with 2 sutures placed circumferentially around the esophagus, the first capturing the mucosa and the second secured the muscle.
14. The conduit is brought up in the chest and the tip opened along the staple line for a length of 2cm. The will allow for entrance of the stapler.
15. The fan retractor is removed and a grasper placed through the port site.
16. The stapler is brought in to the chest and placed through the tip of the conduit. The “spike” is brought out along the greater curve, typically above where the epiploic artery ends.
17. Attached to the anvil, secured down and fired. Must confirm two complete ringsof stomach and esophagus.
18. The open gastrotomy is closed with several application of a thick tissue Endo GIA stapler.
19. The nasogastric tube is advanced, two drains placed and rib blocks of 0.5% Marcaine are instilled.
20. Lung re-expanded, chest closed and transferred to recovery.