This document describes a technique for performing a single layer continuous hand-sewn esophagogastric anastomosis during a thoracolaparoscopic Ivor Lewis esophagectomy. The technique was performed on 5 patients with lower esophageal adenocarcinoma. No intraoperative complications or postoperative anastomotic leaks occurred. The mean operative time was 338 minutes and mean hospital stay was 8 days. This preliminary study suggests the technique of a thoracoscopic single layer continuous hand-sewn anastomosis is a feasible and safe method for esophagogastric anastomosis during minimally invasive Ivor Lewis esophagectomy. However, larger comparative studies are still needed to fully validate this technique.

1. SINGLE LAYER CONTINUOUS HAND
SUTURED ESOPHAGOGASTRIC
ANASTOMOSIS IN
THORACOLAPAROSCOPIC IVOR LEWIS
ESOPHAGECTOMY FOR LOWER
ESOPHAGEAL CARCINOMA
Dr. Pradeep jain
Director
Department of Laparoscopic GI, GI Oncology, Bariatric and Minimal Access
Surgery
Fortis Hospital, Shalimar Bagh, New Delhi

2. Introduction
 Minimally invasive Ivor-Lewis Esophagectomy - a
technically challenging procedure but good results in
hand of experts
 The major post op morbidity is often related to
anastomotic leak
 Various methods used to create esophagogastric
anastomosis for the want of perfect anastomosis
 Still the leak rate of 0-10% and stenosis 0-25%
 So far no Thoracoscopic single layer continuous hand
sewn anastomosis reported

3. AIM
 To see the safety of thoracoscopic hand
sutured single layer continuous anastomosis
with monofilament absorbable suture

4. Methodology
 SETTING
This study was conducted in Department of Laparoscopic
GI, GI Oncology, Bariatric and Minimal Access Surgery, Fortis
Hospital, Shalimar Bagh, New Delhi from July 2012 and July
2013.
 STUDY DESIGN
Prospectively collected data of 5 patient were
retrospectively reviewed
 SAMPLE SIZE
5 patients(4 distal esophageal adenocarcinoma and 1
gastroesophageal adeno carcinoma) in the age group of 55-
72 years who underwent thoracolaparoscopic Ivor Lewis
esophagectomy

5. Methodology
INCLUSION CRITERIA
 Adeno carcinoma of lower 1/3rd of esophagus and GE
junction tumors
 Radiologically upto T3 stage tumors
 Post Chemotherapy downstaged locally advanced tumor
EXCLUSION CRITERIA
 Upper and middle 1/3rd esophageal tumors
 Metastatic tumors

6. Methodology
Techniques:
First stage- Abdominal portion
 Patient was placed in Lloyd davis position.
 Pneumoperitoneum was created and 5 abdominal ports were
placed.
 Taking care of lower esophageal/ GE junction tumor esophageal
hiatus was dissected.
 Omentum was divided beyond greater curvature gastric arcade.
 Celiac lymphnodal dissection was done and left gastric vessels
were ligated at their origin.
 Gastric tube created by sequential firings of endo GIA stapler (blue
cartridge) started just below crow’s foot to gastric fundus 7-10 cm
away from tumor margin.
 Pyloroplasty was not done.
 Feeding jejunostomy was done 20 cm distal to duodenojejunal
flexure.

7. Methodology
Second stage- Thoracic part
 Patient was placed in prone position.
 Four ports were placed in right pleural cavity.
 Azygous vein was clipped and divided. Esophagus dissected
from surrounding structures along with peri esophageal,
subcarinal and hiatal lymph nodes.
 Thoracic esophagus divided just at the level of azygus vein
and gastric tube pulled into thoracic cavity along with lower
esophagus with tumor.
 Upper end of gastric tube divided and thoracoscopic end to
end single layer continuous esophagogastric anastomosis
was created by 2-0 PDS suture.
 Specimen was put into endobag and extracted outside
through 5 cm thoracotomy wound.

8. video

9. Methodology
Postoperative care:
 Feeding by jejunostomy tube was started the very next
day
 On third post operative day Gastrograffin study was
performed and oral liquids were started
 By seventh postoperative day patients were shifted to
semisolid diet

10. Results
 Five patients (mean age 62 years; range 55 to 72) with
distal esophageal adenocarcinoma (n=4) and
gastroesophageal adeno carcinoma (n=1) undewent
thoracolaparoscopic Ivor Lewis Esophagectomy
between July 2012 and July 2013
 Out of five patients two patients had received
neoadjuvant chemotherapy
 Mean blood loss during surgery 310 ml
 Mean operative time – 338 minutes
 Mean hospital stay- 8 days

11. Results
 No intra-operative complications, anastomotic
leak, postoperative major postoperative morbidity or
deaths
 On HPE proximal, distal and radial margins were free
from malignant cells
 A median of 15 lymph nodes (range 13 to 22) were
dissected from each specimen
 Follow up period 2.5 months to 1 year

12. Discussion
Major morbidity after Intrathorasic anastomosis revolves around integrity of
intrathorasic anastomosis
very few reports of thoracoscopic manual anastomosis in literature (two
layered or interrupted ) with varying rates of leak
In our method thoracoscopic , manual, single layer, continuous, monofilament
absorbable appears to be safe as there was no leak or post op dysphasia
watson DI, et al . Totally endoscopic Ivor Lewis esophagectomy. Surg.endoscopy.1999;13(3):293-297
Cadiere et al .Ivor Lewis esophagectomy with manual esophagogastric anastomosis by thoracoscopy in prone position
and laparoscopy. Surg. Endoscopy 2010 June;24(6):1482-5
Behzadi A et al . Esophagectomy: The influence of stapled versus hand –sewn anastomosis on outcome . J
Gasrointest Surg. 2005 Nov 9(8) : 1031-40
Blackmon SH et al . Propensity matched analusis of three techniques for Intrathorasic anastomosis . Ann Thorac Surg
2007 May; 83(5) 1805-13
Single layer, continuous, hand sewn method for esophageal anastomosis. Prospective evaluation in 218 patients .
Simon Law et al. Arch Surg 2005; 140(1): 33-39

13. Conclusion
Single layer continuous hand sutured esophagogastric
anastomosis is feasible and as safe as any other
methods of anastomosis in minimally invasive Ivor Lewis
esophagectomy.
This is faster and cheaper
However for the validation of this technique , a large
prospective comparative studies between various
anastomotic methods are required

14. Thanks