From February 2013 through June 2018, 190 patients underwent minimally invasive Ivor Lewis esophagectomy via the one-stage approach. General anesthesia is induced, and the patient is intubated with a dual-lumen endotracheal tube. We routinely insert an arterial line and Foley catheter and selectively use central venous lines.
Once appropriate access is obtained, the patient’s upper torso and shoulders are rotated toward the left with the right arm brought across chest into the “corkscrew” position. Because the patient is not fully lateral, an axillary roll is not used. Lateral body supports (Allen Medical Systems, Acton, MA, USA) are placed bilaterally at the hips and at the left chest wall. The right chest is rotated toward the patient’s left with another lateral body support behind the right scapula, taking care to ensure that the inferior angle of the scapula can be prepped into the sterile field. The patient’s right arm is supported on a padded arm support (Skytron, LLC., Grand Rapids, MI, USA) and secured in place with gauze (Figs. 1 and 2). The abdomen, right chest, and right axilla are all prepped into the sterile field. The operation is performed in four phases.
Phase I: laparoscopy part 1
The OR table is tilted 15–20° to the right. A 7-cm midline incision is made in the epigastrium for placement of a hand port. Three 5-mm ports are placed in the left upper quadrant inferior to the costal margin. Most of the first phase involves foregut mobilization beginning with mobilization of the greater curve of the stomach with a bipolar energy device. The stomach is then retracted anteriorly, exposing the origin of the left gastric artery and the celiac trunk. Nodal tissue around the left gastric artery and celiac axis is dissected and remains with the specimen. The left gastric artery is divided with a vascular load linear stapler. The duodenum is mobilized with a generous Kocher maneuver. The peritoneum anterior to the esophagogastric junction is incised and the fat pad and paraesophageal nodes in the lower mediastinum harvested. The right pleura is then entered widely lateral to the aorta and posterior to the esophagus.
Phase II: thoracoscopy part 1
The OR table is tilted 20° to the left and the right lung is deflated. A 5-mm optical port is used to enter the right chest inferior to tip of scapula, which is insufflated with 8 mmHg CO2. Two 12-mm ports are placed along the anterior axillary line, a 5-mm posterior-inferior port is positioned, and a 3-cm incision made for the circular stapler. The esophagus is dissected to obtain sufficient length to ensure adequate margins and to allow for a tension-free anastomosis, and then divided with a linear stapler. In general, the esophagus is transected at or above the level of the azygous vein. Periesophageal lymph nodes are harvested with the specimen, stripping nodal tissue from the aorta, pericardium, and left pleura. Dissection of paratracheal nodes is performed only for tumor of the middle third of the esophagus. The right pleura is incised both anterior and posterior to the esophagus to optimize lymph node harvest.
Phase III: laparoscopy part 2
The OR table is again tilted 15–20° to the right for the second laparoscopic phase. The distal esophagus and stomach are delivered from the abdomen through the hand port. The specimen is then splayed out, placing gentle tension on the greater curvature to avoid the risk of foreshortening the gastric staple line. The decussation of the right and left gastric arteries is identified approximately 10 cm proximal to the pylorus and divided. We use a combination of Doppler and intraoperative indocyanine green fluorescence angiography to ensure good vascular supply of the gastric conduit which in our experience is associated with fewer anastomotic leaks.8 The conduit is constructed from the greater curvature with multiple firings of a linear stapler to construct a 5-cm wide tube. Frozen sections are obtained from the specimen of the proximal and distal margins. A gastric drainage procedure is performed, followed by a jejunostomy. The conduit is now placed into the right chest through the hiatus. Three 19 Fr Blake drains are now placed: left pleura through the hiatus, right pleura through the hiatus, and abdomen.
Phase IV: thoracoscopy part 2
The OR table is again tilted 20° to the left and the lung reflected. The azygous vein is divided with a linear stapler. The esophageal staple line is fenestrated to allow passage of a 25 mm OrVil™ device (Covidien, North Haven, CT, USA) as described by Nguyen et al.9 The gastric conduit is then positioned in the posterior mediastinum and opened along the lesser curve staple line. A 25 mm DST Series™ EEA™ XL stapler (Covidien, North Haven, CT, USA) is then placed into the conduit and the spike is brought out through the greater curvature. The stapler components are docked and the stapler fired, and the anastomosis is completed with a linear stapler. Ultrasound is used to guide the placement of an 18 Fr nasogastric tube within the gastric conduit. The right pleural 19 Fr Blake drain is positioned posterior to the conduit adjacent to the anastomosis. A 28 Fr chest tube is placed into the right chest and the lung is reinflated, and the thoracoscopic incisions are closed.
Postoperatively, patients are admitted to the intensive care unit and are either extubated immediately or are aggressively weaned from the ventilator upon arrival. We start tube feedings on the day of surgery via the jejunostomy tube. Drain output is checked daily for elevated amylase. A limited upper GI series with water-soluble contrast is performed between the second and fourth post-operative day to evaluate gastric emptying prior to nasogastric tube removal. If there are clinical signs of anastomotic leak or elevation in drain amylase levels, a computed tomography esophagram is performed. Patients are started on sips of water immediately after removal of the nasogastric tube and are discharged taking high-protein shakes.