Transhiatal Esophagectomy
In this procedure, the mediastinal dissection of the esophagus is done from below (through the esophageal hiatus during the laparotomy phase) and from above (through a left neck incision). When successful, thoracotomy and the associated morbidity are avoided. The surgeon should be prepared to perform a thoracotomy if difficulties, including bleeding, occur.
The operation may be performed for benign disease or for selected patients with esophageal carcinoma. Accurate preoperative staging is essential. Tumors of the upper and middle third of the esophagus must be shown not to be adherent to adjacent structures.
Steps in Procedure
Supine position, head turned slightly to the right
Upper Midline Incision, Thorough Abdominal Exploration
Mobilize the stomach, preserving vascular arcades
Incise phrenoesophageal membrane
Encircle distal esophagus with Penrose drain
Gently circumferentially mobilize distal esophagus
Wide Kocher maneuver
Pyloromyotomy
Feeding jejunostomy (if desired)
Incision Along Anterior Border of Sternocleidomastoid Muscle
Divide omohyoid muscle
Retract carotid sheath laterally and trachea and esophagus medially
Divide middle thyroid vein
Circumferentially mobilize esophagus and encircle with Penrose drain
Mediastinal Dissection
Posterior mobilization by passing a sponge stick down from above, hand up from below
Similar anterior mobilization
Lateral mobilization performed last
Pull several centimeters of esophagus into cervical wound
Divide with GIA
Pull stomach and esophagus down into abdomen
Divide proximal stomach with GIA
Check hemostasis in mediastinal tunnel and ensure that it is large enough
Pass stomach up into neck
GIA anastomosis of stomach with esophagus
Hand sew rest of anastomosis
Close incisions without drainage
Check chest x-ray, place chest tubes if pneumothorax or hemothorax present
Hallmark Anatomic Complications
Injury to recurrent laryngeal nerve
Injury to azygos vein
Injury to posterior (membranous) portion of trachea
Anastomotic leak
Pneumothorax
Anatomic Structures
Esophagus
Stomach
Pylorus
Gastroepiploic arteries and veins
Lesser curvature
Short gastric arteries
Left gastric artery
Azygos vein
Trachea
Carotid sheath
Sternocleidomastoid muscle
Omohyoid muscle
Middle thyroid vein
Although the operation was, in the past, termed blind or blunt esophagectomy; in reality, only a very small part of the dissection is performed without visual control. This chapter gives the basic steps in the procedure. More detailed accounts are given in the references at the end.
Patient Position and Initial Abdominal Dissection (Fig. 32.1)
Technical Points
Position the patient supine, with the head turned slightly to the right and the neck slightly extended by a roll under the shoulders. In addition to the usual monitoring devices, place an indwelling arterial line so that blood pressure can accurately be measured on a beat-to-beat basis. Compression on the heart and vena cava during the mediastinal dissection may cause hemodynamic compromise, and accurate blood pressure monitoring and communication between surgeon and anesthesiologist are crucial during this operation.
Begin with an upper midline incision and thorough abdominal exploration, including palpation of liver and regional nodes, to confirm that resection is appropriate. Take down the triangular ligament of the liver and fold it to the right, placing a padded retractor over it (Fig. 32.1) to provide wide exposure of the gastroesophageal hiatus and distal esophagus.
Mobilize the stomach as described in Chapter 28, taking care to preserve the vascular arcades along the lesser and greater curvature.
Next, incise the peritoneum overlying the esophageal hiatus and divide the phrenoesophageal membrane. Encircle the distal esophagus with a Penrose drain (Fig. 32.2) and place gentle downward traction on it. Place a heart-shaped retractor on the esophageal hiatus and elevate it, providing direct exposure into the lower mediastinum. Enter the mediastinum, gently displacing the pleura to each side of the esophagus and taking care not to enter the pleura. Progress upward, gently assessing mobility of the esophagus and circumferentially mobilizing it by sequentially dividing fibrous attachments and small vessels with electrocautery under direct vision. Take periesophageal soft tissues with this dissection and slowly proceed to the level of the carina.
Place a pack in the mediastinum. Perform a wide Kocher maneuver (if not already done) and a pyloromyotomy. If desired, a feeding jejunostomy can be done at this stage to complete the abdominal phase of the operation.
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