This document describes the technique for a thoracolaparoscopic esophagectomy. It summarizes the steps including: 1) Initial thoracoscopic dissection of the esophagus in the chest, with ligation of vessels and azygos vein. 2) Laparoscopic mobilization of the stomach and dissection of the esophagus in the abdomen. 3) Creation of a gastric conduit and cervical anastomosis through a neck incision. The minimally invasive approach allows for better exposure during dissection, less pulmonary morbidity, and shorter hospital stays compared to open surgery. Evidence is accumulating that it may provide benefits over open esophagectomy.

1. Thoroacolaparoscopic
Esophagectomy
Dr. K. Sendhil Kumar
MS, FICS, FACS(USA), DNB(SURG GASTRO)
Dr. Piyush Patwa
MBBS. DNB, FMAS, FIAGES, FAIS
Gateway Clinics, Coimbatore
MINIMALLY INVASIVE ESOPHAGECTOMY

2. INITIAL EXPERIENCE
Early on Minimally Invasive Esophagectomy Lacked a Consistent
Minimally Invasive Approach
• Right VATS, laparotomy and neck incision
• Laparotomy for gastric mobilization, thoracoscopic esophagectomy
and intrathoracic anastomosis
• Laparoscopic gastric mobilization, thoracotomy with intrathoracic
anastomosis
• Thoracoscopic esophagectomy, laparoscopic hand-assisted
• Totally laparoscopic mobilization, esophagectomy with neck
anastomosis (Transhiatal)
No advantages noted at that time, but clearly no consistent approach
had emerged

3. Totally Laparoscopic / Thoracoscopic
• Thoracoscopic esophagectomy, laparoscopic
gastric mobilization and cervical anastomosis
(McKeown)
• Laparoscopic gastric mobilization,
thoracoscopy with intrathoracic anastomosis
(Ivor Lewis)
• RAMIE

4. THORACOLAPAROSCOPY
ADVANTAGES
• Better exposure /Dissection of mediastinum
• Better esophageal margins
• ? Survival/local recurrence benefit

5. THORACOLAPAROSCOPY
with NECK ANASTOMOSIS
DISADVANTAGES
• Repositioning required
• Double lumen tube required (optional)
• Delayed abdominal assessment
• Gastric tip ischemia
• Gastric margins
• RLN injury

6. Patient Position

7. Planning Thoracoscopy port placement

8. Thoracoscopy - 10mm scope & two 5 mm working ports

9. RIGHT THORACOSCOPY
• SEMILATERAL POSITION
• DOUBLE LUNG VENTILATION
• CO2 PNEUMOTHORAX
• 8 mm Hg PRESSURE
• 3 WORKNG PORTS

10. INITIAL THORACOSCOPIC VIEW
SPINE AND RIBS PARTIALLY COLLAPSED LUNG
ORIENT YOURSELF
POSTERIOR
ANTERIOR

11. AZYGOS CROSSING TRACHEAL BIFURCATION
RIGHT BRONCHUS
TRACHEA
ONLY STRUCTURE WHICH NEEDS TO BE LIGATED

12. Looking at distal end of Oesophagus
DIAPHRAGM
COLLAPSED LUNG

13. SVC
OESOPHAGUS
TRACHEA
HILUM
Initial View and Orientation
INTERCOSTAL VESSELS
AZYGOS VEIN

14. Superior vena cava
Right subclavian artery
IJV
SCV
Initial View and Orientation

15. SYMPATHETIC NERVES
OESOPHAGUS
LOOKS LIKE A NARROW WINDOW

16. VAGUS NERVE

17. STARTING POINT
OESOPHAGUS
BE CAREFUL ABOUT AZYGOS VEIN AND THORACIC DUCT

18. STARTING POINT
MEDIASTINAL PLEURA
PNEUMOTHORAX HELPS IN DISSECTION

19. ENCIRCLE IT HERE

20. DIRECT BLOOD SUPPLY FROM THE AORTA

21. DIRECT BLOOD SUPPLY FROM THE AORTA
COAGULATE ALL THESE VESSELS NICELY TO KEEP THE OPERATIVE FIELD CLEAN

22. PERICARDIUM

23. PERICARDIUM

24. INFERIOR PULMONARY LIGAMENT
AND RIGHT CRUS
RT CRUS

25. RIGHT CRUS
RT CRUS

26. DISSECTED LOWER OESOPHAGUS
PERICARDIUM
DIAPHRAGM
LUNG

27. PROXIMAL 1/3RD OESOPHAGUS
BEWARE OF MEMBRANEOUS PART OF THE TRACHEA DURING DISSECTION

28. CROSSING THE OESOPHAGUS & TRACHEAL
BIFURCATION BEFORE JOINING SVC

29. PROXIMAL LIGATION FIRST!!!

30. TRACHEA AND RIGHT BRONCHUS
MEMBRANOUS PART OF THE RIGHT BRONCHUS IS SEEN NICELY

31. ANOTHER VIEW OF BRONCHUS

32. SECURE IT WELL!!!

33. ONLY STUCTURE TO BE DIVIDED

34. SUB-CARINAL NODES
PERICARDIUM
RT BRONCHUS
LEFT BRONCHUS

35. INFRA- CARINAL AREA
BIFURCATION

36. GOING INTO THE ABDOMEN
BY LAPAROSCOPY
• SEMILITHOTOMY POSITION
• PNEUMOPERITONEUM
• 5 PORTS
• 12-14 mm Hg PRESSURE
• ULTRASONIC ENERGY AND VESSEL SEALING
SYSTEM
• STEEP REVERSE TRENDELENBURG’S TILT

37. Position

39. EXPOSURE OF THE
ABDOMINAL OESOPHAGUS
STOMACH
LEFT LOBE LIVER

40. SIMPLE WAY OF EXPOSURE
LEFT LOBE LIVER
STOMACH
HEPATIC BRANCH OF
VAGUS

41. ORIENTATION
CAUDATE
LOBE
LEFT GASTRIC
PEDICLE
STOMACH
LEFT LOBE LIVER
HEPATIC BRANCH
OF VAGUS

42. STARTING THE DISSECTION
GASTRO HEPATIC
LIGAMENT
KUTZNER WINDOW
LEFT LOBE LIVER
UNDER SURFACE OF DIAPHRAGM

43. AFTER DIVIDING THE GASTROHEPATIC LIGAMENT
LEFT LOBE
LIVER
CAUDATE
LOBE
COMMON
HAPATIC ARTERY
LEFT GASTRIC
VEIN
RT
CRUS
APPRECIATE THE ANATOMY BEFORE DISSECTING

44. RIGHT CRUS
RT CRUS.
WHITE
LINE
CAUDATE
LOBE
ESOPHAGUS
IMPORTANT LANDMARK

45. ANTERIOR VAGUS

46. ANTERIOR
VAGUS
STOMACH
ESOPHAGUS
RT
CRUS
LEFT LOBE
LIVER
ANTERIOR VAGUS

47. GOING AROUND THE OESOPHAGUS
BARE AREA OF
STOMACH
STOMACH
ESOPHAGUS
DEPRESS THE OGJ

48. BARE AREA OF THE STOMACH
AVOID INFERIOR PHRENIC VESSELS
INFERIOR PHRENIC VESSEL
STOMACH
ESOPHAGUS
BARE AREA OF STOMACH

49. PHRENO OESOPHAGEAL MEMBRANE
PHRENO
ESOPHAGEAL
MEMBRANE
ESOPHAGUS
RT CRUS
LIFT THE OESOPHAGUS

50. IDENTIFY AND FOLLOW THE LEFT CRUS
RETRO
ESOPHAGEAL
WINDOW
RT
CRUS LT CRUS

51. RETRO ESOPHAGEAL WINDOW
IMPORTANCE OF THE SURGICAL PLANES

52. POSTERIOR VAGUS
POSTERIOR VAGUS
ESOPHAGUS
RT
CRUS
LEFT
CRUS
TAKE IT ALONG THE OESOPHAGUS IN ANTIREFLUX PROCEDURES

53. AORTA IS TOO CLOSE
AORTA
RT CRUS
LT
CRUS
ESOPHAGUS

54. CERVICAL OESOPHAGUS
SKIN CREASE INCISION

55. OESOPHAGUS

56. OESOPHAGUS
NO TRAUMA OR UNDUE STRETCHING

57. INCISING THE MUSCLE

58. INCISING THE MUSCLE

60. PORTS/SCARS

61. Mucosal Tube
LEAVE EXTRA LENGTH OF MUCOSA AT THE PROXIMAL OESOPHAGUS

62. Hiatus
Gastric tube is seen through the hiatus
IVORLEWISPROCEDURE

64. Summary
• Minimally invasive techniques can be used to
perform most Esophagectomy procedures
• Evidence of patient benefit is starting to accumulate
in both retrospective single centre studies &
prospective, multi-centre trials.
• Less chance of pulmonary morbidity – Shorter
hospitalization

65. Please watch the video with the link given below
• https://www.youtube.com/watch?v=06deeIH
aAN8

66. Dr. K. Sendhil Kumar
Dr. Piyush Patwa
Gateway Clinics, Coimbatore