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Minimally Invasive Three-Field Esophagectomy

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Abstract

There are various methods of esophageal cancer surgery. The location of the tumor, the selection of the organ as the esophageal substitute, the route of the conduit, and the level of planned anastomosis are important anatomic factors that surgeons should consider for successful surgery. If the tumor is located in the upper thoracic esophagus, the three-field (cervical, thoracic, and abdominal) approach is usually required to guarantee a sufficient resection margin.In this chapter I describe the surgical techniquefor minimally invasive three-field esophagectomy in detail.

Keywords

  • Esophageal cancer
  • Esophagectomy
  • Three-field
  • Minimally invasive surgery
  • Video-assisted surgery

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Correspondence to Young Tae Kim M.D., Ph.D. .

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In this video the surgeon demonstrates his approach to minimally invasive three-field esophagectomy. (MOV 884751 kb)

Key Operative Steps

Thoracoscopic Dissection

  1. 1.

    Begin dissection below the carina.

  2. 2.

    Incise the mediastinal pleural along the anterior surface of the esophagus and dissect the esophagus on the pericardium and the aorta.

  3. 3.

    Incise the mediastinal pleura along the posterior surface of the esophagus. Place a sponge between the aorta and esophagus to facilitate posterior dissection.

  4. 4.

    Once circumferential dissection is completed, place a penrose drain to retract the esophagus.

  5. 5.

    Control small perforators from aorta with clips or energy device.

  6. 6.

    Dissect all para-esophageal lymph nodes en bloc with the esophagus.

  7. 7.

    Resect thoracic duct en bloc with the esophagus.

  8. 8.

    Subcarinal lymph nodes should be dissected en bloc with the esophagus.

  9. 9.

    Divide the azygos vein with an endostapler.

  10. 10.

    Dissect the upper thoracic esophagus. Ensure complete dissection of the esophagus from the esophageal hiatus to the thoracic inlet.

  11. 11.

    Perform upper mediastinal lymph node dissection.

Preparation of Gastric Conduit

  1. 1.

    Open the lesser sac and divide up to the hiatus.

  2. 2.

    Start dissection of the greater omentum using an energy device.

  3. 3.

    Divide the short gastric vessels.

  4. 4.

    Divide the left gastric vessels with vascular clips or an endostapler.

  5. 5.

    Dissect the left gastric artery lymph nodes en bloc with the specimen.

  6. 6.

    Perform pyloric drainage procedure or inject Botox into the pylorus.

Cervical Dissection and Anastomosis

  1. 1.

    Make oblique left neck incision, divide the platysma, and retract the sternocleidomastoid.

  2. 2.

    Divide the middle thyroidal vessels and omohyoid muscle.

  3. 3.

    Retract the thyroid gland medially and dissect the posterior esophagus.

  4. 4.

    Encircle the cervical esophagus with a penrose drain.

  5. 5.

    Perform blunt dissection inferiorly to join dissection plane in the right chest.

  6. 6.

    Construct the gastric conduit and bring up to the neck.

  7. 7.

    Divide the cervical esophagus and perform esophagogastric anastomosis.

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Kim, Y.T. (2015). Minimally Invasive Three-Field 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_5

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  • DOI: https://doi.org/10.1007/978-1-4939-1893-5_5

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