Minimally Invasive Ivor Lewis Esophagectomy

Abstract

Minimally invasive Ivor Lewis esophagectomy can be performed with low morbidity and is the preferred operation for gastroesophageal junction tumors at our institution. We inject botulinum toxin into the pylorus endoscopically rather than performing pyloromyotomy or pyloroplasty. The gastric conduit is created laparoscopically. Lymph nodes at the base of the left gastric artery and celiac trunk are removed and a feeding jejunostomy catheter is routinely placed. The chest portion of the operation is performed robotically, mobilizing the esophagus and performing a complete mediastinal and paraesophageal lymphadenectomy. The anastomosis is made with a circular stapler at the level of the azygos vein and an omental flap is interposed between the anastomosis and the trachea.

Key Operative Steps

• 1. Esophagogastroduodenoscopy is performed prior to surgical resection. Inject the pylorus with botulinum toxin (200 units) and perform dilatation.

• 2. Ports are placed for laparoscopic mobilization of the stomach.

• 3. Dissection is started at the hiatus with exposure of the right and then left crus.

• 4. The right gastroepiploic artery is identified and the stomach is separated from the omentum and transverse mesocolon.

• 5. Harvest an omental flap by leaving a pedicled portion of the omentum perfused by 2–3 branches of the right gastroepiploic artery.

• 6. Divide the short gastric arteries.

• 7. Lift the stomach in the air to expose the left gastric artery. Sweep the lymphatic tissues towards the specimen. Divide the left gastric pedicle with an endo-vascular stapler.

• 8. Dissect the posterior gastroesophageal junction.

• 9. Pull the nasogastric tube back into the pharynx. Divide the stomach in between the right and left gastric arteries on the lesser curvature of the stomach just proximal to the incisura. Create a gastric conduit at least 4 cm in width up to the fundus.

• 10. Place a feeding jejunostomy catheter.

• 11. Position the patient for the chest portion of the operation.

• 12. Divide the inferior pulmonary ligament and remove lymph nodes at that station.

• 13. Retract the lung and divide the azygos vein with a vascular stapler.

• 14. Open the mediastinal pleura overlying the esophagus (anteriorly and posteriorly).

• 15. Mobilize the esophagus circumferentially and ligate small perforating vessels.

• 16. Encircle the esophagus with a penrose drain for retraction.

• 17. Resect the network of lymphatics overlying the aorta.

• 18. Excise the lymphatic tissues in the subcarinal lymph node station. Divide the bronchial branches of the vagus nerve and the main bronchial artery to the right mainstem bronchus.

• 19. Ligate the thoracic duct.

• 20. Pull the gastric conduit into the chest and divide the esophagus at the level of the azygos vein.

• 21. Create an esophagogastrostomy with a circular stapler.

• 22. Place a chest tube and blake drain in the posterior mediastinum.