Left Thoracophrenotomy / Thoracoabdominal Approaches

A number of variations exist in this surgical approach to lower 3rd tumours.

1. Isolated left Thoracotomy and phrenotomy without division of costal margin

2. Isolated left  Thoracoabdominal approach

3. Isolated left Thoracotomy and phrenotomy without division of costal margin but with cervical incision

4. Isolated left  Thoracoabdominal approach with cervical incision

Notes

1. Phrenotomy without division of costal margin means opening of diaphragm to mobilise stomach without dividing costal margin

2. Cervical incision is utilised when a higher proximal anastomosis is required, as in total oesophagectomy. The cervical incision is usually made on the side of the thoracotomy so that it remains very unlikely that both recurrent laryngeal nerves could be bruised / injured

3. The stomach is the main conduit for oesophageal replacement

4. The anastomosis between oesophageal remnant and oesophageal conduit can be stapled or hand sewn. ( in the chest it tends to be stapled, and in the neck it tends to be hand sewn)

5. It is said should the anastomosis leak, a neck anastomosis will not only be easily detected, and thus opened to drain, but will also be less likely to cause potentially fatal mediasteinitis

History

A 65 year old gentleman with proven adenocarcinoma at the oesophag0-gastric junction

Operative steps

Patient positioning. Usually slightly more left shoulder back. A bean bag helps in patient stability

A posterior lateral incision is made at about the level of the sixth / seventh or eighth intercostal space. After the retractors are placed, the diaphragm is easily exposed through the incision. The inferior pulmonary ligament is then incised after a thorough exploration of the pleura and lung has been performed.

The tumour is identified in the mediastinal pleura. The dissection of the oesophagus is aided by the prior placement of a nasal gastric tube. A tape is then placed around the mobilised oesophagus and the dissection is continued to around the location of the tumour taking wide margins of the mediastinal tissue.

Once mobilization has been completed the diaphragm is then incised. This can be either radial or circumferential in fashion, approximately 4-5 cm from the costal margin. This incision then exposes the abdominal contents.

The greater omentum is identified and dissected away from the gastroepiploic arcade along the greater curvature of the stomach. 

The stomach is mobilised

This dissection is continued to the short gastric which are ligated separating the stomach from the spleen at the gastrosplenic ligament. The lesser omentum is entered and transected preserving if possible the right gastric artery. A generous Kochler maneuver is then performed detaching the retroperitoneal attachments of the second through the third and proximal fourth portion of the duodenum. The left gastric arteries are then identified and transected along with the peri coeliac lymph nodal tissue.

The left gastric artery is double suture ligated. (Artery indicated by white arrows)

For tumours that are located at the oesophageal hiatus and into the diaphragm, a sufficient diaphragm may be resected with the specimen to achieve a negative margin. A pyloric emptying procedure is then performed by some surgeons; either a pyloriplasty, pylorimyotomy, or a pylorimyomectomy.

A cephalad transection site is then chosen approximately 10 cm above the most superior portion of the oesophageal tumour. The gastric margin is approximately 5 cm from the lowest portion. 

The lesser curve is divided to allow creation of gastric tube

Stomach is put under light tension for stapling

We usually use the TCT75 to divide the stomach

The stapled free gastric edge is oversewn 

The new gastric neo-oesophagus is then pulled up into the retromediastinum and an anastomosis performed. An end-to-end or functional end-to-side anastomosis can then be performed. Using either a single layer or two layered hand-sewn anastomosis or by stapling devices.

Upper part of remaining oesophagus with stay sutures to prevent mucosa and adventitia loosing their anatomical position, the stomach tube is just below it at 7 o'clock

Final hand sewn anastomosis

The diaphragmatic incision can then be closed. The apical and basilar chest drains are inserted

The specimen