Introduction

Esophageal cancer is the sixth most frequent cause of cancer death worldwide and affects more than 450,000 people all over the world [1]. Most patients with esophageal cancer in Asian countries such as Japan and China have squamous cell carcinoma (SCC), while most of those in Western countries have adenocarcinoma [2, 3]. In particular, the incidence of esophageal adenocarcinoma in the USA and the UK is rapidly increasing, in which the age-adjusted incidence has risen by 39·6% for men and 37·5% for women every 5 years in the UK [3]. Despite improvements in surgical techniques and perioperative management [4, 5] and surgery combined with chemotherapy and/or radiotherapy [6, 7], the prognosis of esophageal cancer at advanced stage remains poor with 30–40% in a 5-year survival globally [8] and the 5-year survival rate for the patients receiving esophagectomy in Japan was 55.5% [9].

It is generally accepted that conventional open surgical procedures for esophageal cancer are traumatic and invasive, despite continuous advances in perioperative management and surgical techniques. Since Cuschieri et al. reported thoracoscopic surgery in minimally invasive esophagectomy (MIE) in 1992 [10], MIE has become one of the standard surgical approach for esophageal cancer. A randomized trial of MIE compared with open esophagectomy showed a lower incidence of pulmonary infections, a shorter hospital stay, and better short-term quality of life than did open esophagectomy, with no compromise in the quality of the resected specimen [11]. Moreover, treatment in high-volume centers with experienced surgeons and the availability of critical-care support is associated with improved outcomes [12].

McKeown Esophagectomy

The common surgical approaches to curatively resect esophageal cancer include trans-hiatal, Ivor Lewis, and McKeown (three incision) esophagogastrectomy [13]. McKeown esophagectomy is defined as consisting of thoracic esophageal mobilization with lymph node dissection (thoracoscopic or open), abdominal exploration (laparoscopic or open), and stomach mobilization with lymph node dissection, and subsequently left cervical incision for anastomosis. Potential advantages of the McKeown approach compared to the Ivor Lewis include less incidence of local recurrence, applicable to the tumors at or above the level of carina, and anastomosis in neck easier to manage if anastomotic leak occurs [13]. The issue of two-field (thoracic + abdomen) vs. three-field (thoracic + abdomen + neck) lymph node dissection is still debatable.

McKeown esophagectomy is appropriate for all patients with Siewert type I and II patients, as well as all patients with tumor above the gastroesophageal junction, up to the level of the clavicle. Most importantly, Ivor Lewis should not be applied to tumors at or above the level of carina due to the risk of a positive esophageal surgical margin.

Indications for McKeown Esophagectomy

  • Carcinoma of the upper, middle, and lower third of the esophagus, especially applicable to the tumors above the level of carina.

  • T1a carcinoma not amenable to endoscopic resection, T1b, T2, T3, and T4a.

  • Salvage esophagectomy after definitive chemoradiation.

  • End-stage benign strictures of the esophagus are not amenable to trans-oral dilations (caustic injury, peptic structures).

Contraindications

  • Tracheobronchial, mediastinal, and intra-abdominal structures invasion (T4b).

  • Stage IVb disease.

  • Advanced physiologic age and frailty.

  • Prohibitive comorbidities.

OT Setup

Device

The basic surgical device uses a spatula-type monopolar electric scalpel and LigaSure™ Maryland 37, and a microline scissors for manipulating around the recurrent laryngeal nerve.

Position/Port Position

Raise both hands, and take a prone position with the face fixed by Prone View® and the trunk fixed by a spine surgery operation frame (Spine Table) (Fig. 1). By using the position, interference between the forceps and the operating table is prevented. After intubation of a single lumen spiral tracheal tube, a blocker is placed in the right main bronchus for left single lung ventilation in order to make surgical field stable. Alternatively, both lung ventilation with artificial pneumothorax also can be possible.

Fig. 1
A photograph of a naked patient lying down in a prone position. There are seven markings on the right side of her body, 4 X marks, and 2 arcs.

Position of the patients. Raise both hands, and take a prone position with the face fixed by Prone View® and the trunk fixed by a spine surgery operation frame (Spine Table)

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Port placement starts with four ports as shown in Fig. 2 and 6 mmHg pressure under artificial pneumothorax. First, a 12 mm trocar is inserted into fifth intercostal space (ICS), while observing with a 0° rigid endoscope, and the pleural incision is safely observed under direct vision to prevent lung injury. After confirming the proper insertion of the port into the chest cavity, pneumothorax is initiated and a complete collapse of the right lung is obtained. Thereafter, the endoscope is changed to a 30° rigid endoscope to perform intrathoracic operation. Next, insert a 12 mm port into the ninth ICS as a camera port, and insert a 5 mm port into the seventh ICS and a 5 mm port into the third ICS. The operator uses the fifth and seventh ICS port, and the assistant uses the third ICS port (Figs. 2 and 3).

Fig. 2
A photograph of a patient in a prone position with 4 X marks and 2 marks resembling the greater than and lesser than symbols. The X marks, from the back part going to the armpit area, are labeled as follows. I X I C S Camera Port. V I I I C S Surgeon Port. V I C S Surgeon Port. I I I I C S Assistant Port.

Port insertion

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Fig. 3
A photograph of a patient's side with four different intercostal space ports inserted.

Port

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First, a 12 mm trocar is inserted into V intercostal space (ICS), while observing with a 0°degree rigid endoscope, and the pleural incision is observed under direct vision to prevent lung injury. After confirming the proper insertion of the port into the chest cavity, pneumothorax is initiated and a complete collapse of the right lung is obtained. Thereafter, the endoscope is changed to a 30° rigid endoscope to perform intrathoracic operation. Next, insert a 12 mm port into the ninth ICS as a camera port, and insert a 5 mm port into the seventh ICS and a 5 mm port into the third ICS. The operator uses the fifth and seventh intercostal space port, and the assistant uses the third intercostal space port.

Insert a 12 mm port into the ninth intercostal space as a camera port and the operator uses the 5th (12 mm) and 7th (5 mm) intercostal space port, and the assistant uses the third intercostal space port (5 mm).

Description of the Technique

Dissection of the Azygos Vein

An incision is made in the mediastinum pleura and the azygos vein is isolated with preservation of the right bronchial artery at the backside of the azygos vein. The azygos vein is dissected with Powered ECHELON FLEX® 7 (Fig. 4) and confirm the preservation of the right bronchial artery (Fig. 5). At this point, the camera is moved to the fifth ICS port, and the Powered ECHELON is inserted from the ninth ICS to adjust the axis of the device. The dorsal stump of the azygos vein is grasped by the end loop PDSII® and lifted outward to ensure a visual field near the root of the right bronchial artery.

Fig. 4
A photograph of the dissection of the azygos vein using a surgical instrument.

Azygos vein transection

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Fig. 5
A photograph of the intact right bronchial artery. This part is indicated with an arrow.

Preservation of the right bronchial artery

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Dissection of Lymph Node Along the Rt-recurrent Nerve

The mediastinal pleura is dissected along the right vagus nerve until the right subclavian artery, and the pleura is dissected posteriorly on the right subclavian artery to expose the front surface of the right subclavian artery (Fig. 6). Next, along the right wall of the trachea, the tissue containing the right recurrent laryngeal nerve is mobilized. At this time, the blood vessel plexus on the side wall of the trachea should be preserved to maintain the blood flow for the trachea. This lymphatic tissue is sharply and bluntly dissected with a Microline® scissor to identify and preserve the right recurrent laryngeal nerve and to dissect the lymph node, which is mainly located on the dorsal side (Fig. 6). In the area around the Rt-recurrent laryngeal nerve, the use of an electric scalpel or a vessel sealer should be avoided. Lymph node dissection is performed until the back side of the right subclavian artery and there is a branch of the inferior thyroid artery in the area, so it is essential to prevent bleeding and keep the surgical site dry.

Fig. 6
A photograph of the lymph node dissection, An arrow indicates this part,

Dissection of lymph node along the Rt-recurrent nerve

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Dissection of the Thoracic Duct

In the mediastinum, the ventral side of the azygos vein is mobilized from the Aorta, and the thoracic duct is identified on the ventral side. The ligation of the thoracic duct is based on the collective ligation including the surrounding tissue with the end loop PDSII® or clip (Fig. 7). On the oral side, the thoracic duct was attached to the esophagus. The mid-thoracic and upper thoracic esophagus are separated from the Aortic Arch and the left pleura. In some cases depending on the T- or N-factors, we are preserving the thoracic duct.

Fig. 7
A photograph of the thoracic duct with a clip attached to it. The clip is indicated with an arrow. A surgical device is probing the lower part of the duct.

Dissection of the thoracic duct

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Dissection of Subcarinal Lymph Node

The lower right pulmonary ligament is dissected, and the pleura, the pericardium, and the right pulmonary vein are identified. The right main bronchus is identified near the right hilum, lymph node along Rt-main bronchus, and subcarinal lymph node are dissected at the tracheal bifurcation (Fig. 8), while preserving lung branches from the right vagus nerve. The right vagus nerve is dissected on the peripheral side after the pulmonary branch to maintain the cough reflux (Fig. 9).

Fig. 8
A photograph of the subcarinal lymph node, indicated with an arrow. Several other parts surrounding the node are depicted.

Subcarinal lymph node dissection

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Fig. 9
A photograph of an intact pulmonary branch. There is a double-tipped arrow and an upward arrow depicted in the image.

Preservation of the pulmonary branch of the Rt-vagus nerve

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Dissection of the Lymph Node Along Lt-recurrent Nerve

The upper thoracic esophagus is detached from the left side wall of the trachea and encircles the esophagus at the height of the Aortic Arch and Rt-subclavian artery, by guiding with Endomini Retract®, and stretch the upper thoracic esophagus to upper direction at two positions (Fig. 10). The surrounding tissue including Lt-recurrent laryngeal nerve is mobilized from the trachea and easily identifies the Lt-recurrent laryngeal nerve. Then, using a microline scissors, the left recurrent laryngeal nerve is exposed, and the lymph nodes along the Lt-recurrent nerve are sharply and bluntly dissected (Fig. 11). Thereafter, dissect the esophagus using the Powered ECHELON FLEX® GST system (Fig. 12) and pulling up the oral side of the esophagus to upper direction, lymph node dissection along the Lt-recurrent nerve is performed until the oral side as much as possible, but the dissection from the mediastinum side is completed at the site where adipose tissue is found on the trachea side (pre-tracheal fat), and the lymph node dissection along the Lt-recurrent nerve is continued to the subsequent neck procedure. Over-stretch of the recurrent nerve and use of an electric scalpel or a vessel sealer should be avoided.

Fig. 10
A photograph of the thoracic esophagus with its upper part being stretched in two directions by a retractor.

Encircle the upper thoracic esophagus

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Fig. 11
A photograph of the lymph nodes along the left recurrent laryngeal nerve, indicated with an arrow.

Dissection of lymph node along Lt-recurrent laryngeal nerve

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Fig. 12
A photograph of the upper thoracic esophagus being dissected with a surgical instrument. Its upper part is stretched in two directions with a retractor.

Transection of the upper thoracic esophagus

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By securing the Lt-recurrent laryngeal nerve toward Aortic Arch, and the lymph node surrounded by the left main trachea, the left pulmonary artery wall, the Aortic Arch, and the left vagus nerve is dissected. The left bronchial artery can be identified and it is securely preserved. Care should be taken as damage to the left bronchial artery can lead to major bleeding.

Dissection of Lymph Node in the Mid Mediastinum

By exposing the left main bronchus, pericardium, and left pulmonary vein, lymph node in the mid mediastinum is dissected and attached to the caudal side of the esophagus (Fig. 13). The left vagus nerve is dissected caudally beyond the left main bronchus to preserve the left vagal pulmonary branch.

Fig. 13
A photograph of the lymph node in the mid mediastinum, indicated with an arrow.

Dissection of lymph node in the mid mediastinum

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Lower Mediastinal Lymph Node Dissection

The pericardium, left lung pleura, diaphragmatic limb, and inferior vena cava are exposed and lower mediastinal lymph node is dissected. Several esophageal arteries branched from the descending aorta can be identified and dissected with a vessel sealer.

Drainage for the Chest Cavity

After washing, confirm hemostasis, insert Thoracic drain (24Fr) from the ninth ICS port site.

Neck Lymph Node Dissection

The neck skin incision is based on a collar incision (Fig. 14). The sternocleidomastoid muscle and anterior cervical muscle group are preserved. Supraclavicular lymph node, lymph node along carotid sheath, and lymph node along recurrent laryngeal nerve are dissected on the both left and right sides. The omohyoid muscle is resected, and the transverse carotid artery and vein, and phrenic nerve should be preserved.

Fig. 14
A photograph of an exposed neck over a surgical drape. There are two tubes inserted and a straight suture is done.

Collar incision for neck dissection and anastomosis

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Reconstruction

Our department basically uses the retro-sternal route for reconstruction of the gastric tube, but in cases where the gastric tube cannot be used for reconstruction, such as in cases after gastrectomy, reconstruction of the pedicled jejunum with a vascular anastomosis through the anterior chest wall.

The retro-sternal space is manually separated from caudal side and thereafter, under visual guidance by laparoscopy, the retro-sternal route is made. At the same time, blunt dissection is done from the cervical wound and completes the retro-sternal route. The gastric tube is covered with a sterilized probe cover for ultrasonic waves. While paying attention to the direction so that the gastric tube does not twist, pull the silk thread from the cervical wound and raise the gastric tube. In order to confirm blood supply for the gastric tube, the ICG fluorography is routinely performed (Fig. 15), and it is important to check if the demarcation line is present or not.

Fig. 15
An indocyanine green fluorography image of the gastric tube.

ICG fluorography of the gastric tube

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Apply pediatric intestinal forceps to both ends of the planned cervical esophageal anastomosis, and perform layer-to layer anastomosis with 4–0 monofilament absorbent thread in the interrupted suture fashion (Fig. 16). After completion of the anastomosis, the gastric tube was pulled slightly caudally from the abdomen to straighten the reconstruction route as much as possible, and the excess omentum was dropped into the posterior mediastinum to fill in the posterior mediastinum route so that we can prevent pyothorax when cervical anastomosis leakage occurred.

Fig. 16
An illustration of neck reconstruction depicting the procedures done and instruments used.

Neck anastomosis

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Postoperative Management

It is generally accepted that the McKeown esophagectomy in high-volume centers with experienced surgeons and the availability of critical-care support is associated with improved outcomes [12].

When necessary, bronchoscopy or a mini-tracheostomy can be used to ensure adequate bronchial toilet. Fluid balance and oxygen saturation should be closely monitored and oxygen supplementation is essential. It is also important to provide nutritional support by enteral feeding through jejunostomy routinely placed at the time of surgery.

Thrombosis prophylaxis should be performed by sequential pneumatic compression devices for the first two postoperative days (POD) and subcutaneous injection of low molecular weight heparins. Prophylactic antibiotics are given for 24 h.

Physiotherapy with gradual breathing exercises and general condition exercises is performed from the day of surgery to the day of discharge at least twice a day.

A contrast study to check the integrity of the anastomosis is routinely performed at 5–7 POD. The chest drain will be removed when the effluent amounts to less than 200 mL of fluids.

Patients are discharged when they are able to tolerate the soft diet and the pain is sufficiently controlled to permit normal mobilization. The patient is then seen in the outpatient clinic 1 month after discharge.