%0 Generic %A Irshad, Kashif %D 2018 %T Minimally Invasive Esophagectomy: Tips and Pitfalls %U https://ctsnet.figshare.com/articles/dataset/Minimally_Invasive_Esophagectomy_Tips_and_Pitfalls/6493289 %R 10.25373/ctsnet.6493289.v1 %2 https://ndownloader.figshare.com/files/11938187 %2 https://ndownloader.figshare.com/files/11938205 %K Thoracic %K Esophagectomy %K Surgery %X In this video and article, the author details tips and tricks to help practicing surgeons complete a minimally invasive esophagectomy.
Position of the Patient
The patient lies supine on the bed with a foot rest. This will secure the patient well, especially when a steep reverse Trendelenburg position is required. The patient is placed flush to the right side of the bed. This position adds to the comfort of the operating surgeon and makes the liver retractor more mobile.
Port Placement Pearl: The Rule of Thirds
Mark the patient:
The advantage of a minimally invasive approach is the ability to carefully assess the peritoneal cavity prior to resection, with minimal trauma to the body. The author will spend a few minutes examining the liver, omentum, and abdominal wall prior to resection. Any suspicious lesions are biopsied and sent for frozen section evaluation. This prevents futile resections in those with unsuspected metastatic disease.
Step 1: Hiatal Dissection
Pearl: Reduce the Hiatus Hernia
The author begins this dissection like they do in patients with a hiatus hernia. As the most common cause of esophageal cancer is chronic gastroesophageal reflux disease, it is not surprising that many patients have hiatal hernias. Using the “anterior sac approach,” the author reduces the stomach. This will allow for using more of the stomach to create the conduit.
Step 2: Mobilization of the Stomach
Pearl: Mobilization With Minimal Grasping of the Stomach
Grasping trauma to the stomach is a common criticism of the minimally invasive esophagectomy (MIE). During an open esophagectomy, the stomach is frequently manipulated by the hand, which minimizes iatrogenic trauma. Without this luxury, overly aggressive grasper manipulation can lead to a beaten-up conduit with significant microvascular trauma. This may lead to leak and/or vascular ischemia. To avoid this, the author prefers to use a minimal touch technique to completely mobilize the stomach.
Pearl: Creation of the Omental Flap
The omental flap extends from the halfway point of the gastrocolic omentum to the short gastrics. It allows the surgeon to cover the conduit staple line and the anastomosis. Obviously, it is critical to avoid the colon wall during this dissection.
The Left Gastric Artery
Pearl: The Left Gastric Artery Post
Step 3: The Conduit
Pearl: The Conduit Stretch
After the second gastric firing for the conduit, it is common for the stomach to start folding in on itself and for the stapling angles to be challenging. Creating a nice straight staple line is important for its integrity and length.
Step 4: The Feeding Tube
The author always places a feeding tube. Feedings are slowly begun 24 hours after surgery. The author uses the percutaneous Barone feeding jejunostomy set and the Endo-Stitch to place the feeding tube 25 cm distal to the ligament of Treitz.
Pearl: Perform Extensive Mediastinal Esophageal Dissection Prior to Turning the Patient
Prior to turning the patient and tacking the conduit, the author strongly recommends extensive mediastinal dissection. The exposure through the hiatus is usually excellent, and the distal esophagus can often be mobilized safely to the inferior pulmonary vein.
Pearl: Two-Point Tacking, Recreating Normal Anatomy
In order to prevent a twisting of the conduit as it is pulled up into the right hemithorax, the author sutures the conduit to the specimen at two spots, 1 cm apart.
Learn more: https://www.ctsnet.org/article/minimally-invasive-esophagectomy-tips-and-pitfalls