Laparoscopic Transhiatal Resection for Distal and Gastro-Esophageal Junction Cancer: Operative Technique

Although different neoadjuvant therapies are being developed, surgical treatment remains the only curative therapy for esophageal cancer. For years, the procedure of choice for esophageal cancer was the Ivor-Lewis operation, later modified by McKeown [1]. In this modified procedure, the tumor is resected by means of a right-sided thoraco-tomy combined with a laparotomy using cervical esophago-gastric anastomosis. The advantage of this operation is the perfect exposure that allows complete esophageal dissection and possible en bloc resection. Disadvantages are the pulmonary complications related to the thoracotomy and collapse of the right lung. Pulmonary complications can be overcome by the transhiatal approach as described by Orringer, in which the esophagus is dissected free through the enlarged hiatus [2]. After the esophageal-proximal gastric resection, the created gastric tube is anastomosed with the cervical esophagus through a combined cervical—abdominal approach, thus avoiding a thoracotomy. Disadvantages of this approach are the partly blind resection of the esophagus and the tumor, and that it is limited to tumors of the distal esophagus and gastro-esophageal junction. Both procedures have high complication rates, varying from 40 to 80%, and the in-hospital mortality rate averages 7.5% to less than 5% in experienced centers [3].

The approach and extent of the resection that is necessary is still controversial. In a recent prospective randomized study by Hulscher et al [4], transthoracic esophageal resection with systematic abdominal and mediastinal lymph node dissection (two-field lymph-adenectomy) was compared with the classic transhiatal approach. The transhiatal approach had lower morbidity than the extended lymphadenectomy. Even if a trend was observed with an advantage for the transthoracic approach in tumors located in the mid and distal esophagus, the median survival, disease-free, and quality-adjusted survival for the most common G—E junction cancers were not statistically significant.