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Open Technique for Ivor Lewis Esophagectomy

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For many years, surgical resection of the esophagus and subsequent reconstruction of enteral continuity was a formidable challenge for surgeons and patients alike. Since the first esophageal resection, much has been learned about the anatomical and physiological aspects of esophagectomy. One type of esophageal resection and reconstruction has been referred to as Ivor Lewis esophagectomy, after a British surgeon who utilized an abdominal incision and right thoracotomy to resect the cancer of the esophagus. Herein, we describe our modified approach with this technique.


  • Ivor Lewis
  • Esophagectomy
  • Esophageal cancer
  • Open resection

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Correspondence to Wayne L. Hofstetter M.D. .

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Key Operative Steps

Key Operative Steps

  1. 1.

    Create upper midline incision from the xiphoid to the umbilicus.

  2. 2.

    Retract the left lobe of the liver anteriorly and superiorly over the gastroesophageal junction.

  3. 3.

    Open the pars flaccida exposing the caudate lobe and right diaphragmatic crus.

  4. 4.

    Incise the phreno-esophageal ligament over the diaphragmatic crus and dissect the crus free from the gastroesophageal junction.

  5. 5.

    Pass a penrose drain around the gastroesophageal junction to aid with dissection.

  6. 6.

    Divide the avascular plane between the omentum and colon. Preserve the entire course of the right gastro-epiploic artery.

  7. 7.

    Create an omental pedicle flap, based on 2–3 perforating omental arterial branches off the right gastro-epiploic artery.

  8. 8.

    Complete gastric mobilization along the greater curvature by dividing short gastric arteries.

  9. 9.

    Perform D2 lymphadenectomy and divide the left gastric vessels.

  10. 10.

    Perform either pyloromyotomy or pyloroplasty.

  11. 11.

    Create the gastric conduit with multiple fires of linear stapler from incisura towards the angle of His.

  12. 12.

    Create feeding jejunostomy 30 cm from the ligament of Treitz.

  13. 13.

    Close the abdomen.

  14. 14.

    Perform right thoracotomy.

  15. 15.

    Mobilize the esophagus by incising the inferior pulmonary ligament, retracting the lung anteriorly and medially, and incising the mediastinal pleura along the anterior surface of the esophagus.

  16. 16.

    Mobilize the subcarinal/level 7 lymph node compartment en bloc with the esophagus.

  17. 17.

    Mobilize the azygos arch and divide it with vascular stapler.

  18. 18.

    Mobilize the esophagus away from the trachea.

  19. 19.

    Incise the posterior pleura anterior to the azygos vein and extend inferiorly to the diaphragmatic hiatus.

  20. 20.

    Ligate the thoracic duct between the spine and aorta at T10.

  21. 21.

    Mobilize the esophagus along the periaortic plane to the left pleura with all periesophageal lymphatic tissues.

  22. 22.

    Divide the esophagus at or above the level of the azygos arch.

  23. 23.

    Purse-string the esophagus around the anvil of the stapler.

  24. 24.

    Create gastrotomy at the tip of the gastric conduit and place the circular stapler into the conduit.

  25. 25.

    Open the stapler extending the spike along the greater curvature of the stomach. Align the anvil with the spike and staple the anastomosis.

  26. 26.

    Amputate the tip of the conduit removing the gastrotomy site.

  27. 27.

    Place the omental pedicle flap between the anastomosis and the airway and circumferentially envelop the anastomosis and gastric staple line.

  28. 28.

    Irrigate the chest cavity and place chest tubes in the pleural spaces.

  29. 29.

    Close thoracotomy incision in routine fashion.

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Sepesi, B., Hofstetter, W.L. (2015). Open Technique for Ivor Lewis Esophagectomy. In: Kim, J., Garcia-Aguilar, J. (eds) Surgery for Cancers of the Gastrointestinal Tract. Springer, New York, NY.

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  • Print ISBN: 978-1-4939-1892-8

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