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Open Technique for Transhiatal Esophagectomy

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Abstract

Open transhiatal esophagectomy is a well-established approach that has been shown to be effective and safe with acceptable morbidity and mortality. Indications for transhiatal esophagectomy include both benign and malignant diseases with esophageal carcinoma comprising the majority of cases. Following an appropriate preoperative workup and possible neoadjuvant therapy, the operation is performed in the supine position with access to the left neck, chest, and abdomen. The essential phases of the operation include mobilization of the gastric conduit, pyloric drainage procedure, initial mediastinal dissection, cervical esophageal mobilization, completion of the mediastinal dissection, esophageal and gastric transection with creation of the gastric conduit, and finally cervical esophagogastric anastomosis. Postoperatively the patients are immediately started on an aggressive regimen of pulmonary toilet and physical therapy and tube feedings. Several well-recognized complications that can occur during or after esophagectomy include tracheal tears, major intrathoracic bleeding, recurrent laryngeal nerve injury, anastomotic leak, and thoracic duct leak.

Keywords

  • Esophagectomy
  • Transhiatal
  • Esophageal cancer
  • Esophagogastric anastomosis

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Correspondence to Mark D. Iannettoni M.D., M.B.A. .

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Key Operative Steps

Key Operative Steps

  1. 1.

    Begin the operation with supra-umbilical laparotomy and rule out metastatic disease.

  2. 2.

    Enter lesser sac through the avascular portion of the greater omentum.

  3. 3.

    Divide the short gastric vessels close to the stomach.

  4. 4.

    Separate the omentum 1.5 cm away from the right gastroepiploic artery to the level of the pylorus.

  5. 5.

    Divide the peritoneum over the esophageal hiatus and dissect the esophagus and its fat pad free from the hiatus.

  6. 6.

    Divide the gastrohepatic omentum and isolate and ligate the left gastric vessels.

  7. 7.

    Gastrohepatic, left gastric artery, and celiac axis lymph nodes should be included with the gastric specimen.

  8. 8.

    Preserve the right gastric artery.

  9. 9.

    Perform Kocher maneuver and pylorus drainage procedure.

  10. 10.

    Use Deaver retractor at hiatus for improved exposure.

  11. 11.

    Dissect lymph nodes around distal esophagus to be included with the specimen.

  12. 12.

    The pleural spaces may be entered. Bilateral chest tubes are usually necessary.

  13. 13.

    Divide aorto-esophageal branches. Encircling the distal esophagus with a penrose drain may facilitate this maneuver.

  14. 14.

    Place feeding jejunostomy tube.

  15. 15.

    Create oblique cervical neck incision.

  16. 16.

    Divide platysma and retract sternocleidomastoid and trachea. The middle thyroid vein and inferior thyroid artery may need to be divided.

  17. 17.

    Mobilize the esophagus off the prevertebral fascia posteriorly and dissect free from the soft tissues using blunt and sharp dissection. Avoid injury to the recurrent laryngeal nerve.

  18. 18.

    Elevate the cervical esophagus out of the mediastinum with a penrose drain and bluntly dissect the upper thoracic esophagus to the level of the carina.

  19. 19.

    Place hand up through the hiatus to the right of the spine. Place sponge stick in neck posterior to the esophagus and bluntly dissect until hand in abdomen is reached.

  20. 20.

    Dissect esophagus free from posterior pericardium and carina. Free remaining attachments.

  21. 21.

    Divide esophagus in neck with linear stapler.

  22. 22.

    Create gastric conduit that is 4–5 cm wide and oversew gastric staple line.

  23. 23.

    Advance gastric conduit through the hiatus up to the neck.

  24. 24.

    Close the diaphragmatic hiatus allowing 3 fingers to pass alongside the gastric conduit and secure the conduit to the hiatus with sutures.

  25. 25.

    Perform cervical esophagogastric anastomosis.

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Keech, J.C., Iannettoni, M.D. (2015). Open Technique for Transhiatal Esophagectomy. In: Kim, J., Garcia-Aguilar, J. (eds) Surgery for Cancers of the Gastrointestinal Tract. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1893-5_3

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  • DOI: https://doi.org/10.1007/978-1-4939-1893-5_3

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