Thorascopic Esophagectomy

Because of their age or condition, some patients do not recover well from thoracotomy. The transhiatal approach is one alternative where thoracotomy is sparred, another newly developed approach is the thorascopic esophagectomy. This procedure is of interest because it is the only thoracotomy excluding technique that allows for a complete eosphagectomy and a full lymphadenectomy.

There are three stages to this procedure. The first is the mobilization of the oesophagus by thoracoscopy. The second is construction of a gastroplasty via laparotomy and the third is the cervical anastomosis with the stomach. The last two stages are shared with other alternative approaches to eosphagectomy, only the first is unique.

There are three stages for a thoracoscopic eosphagectomy. The first is the thoracoscopic dissection of the thoracic oesophagus. The second, is the laparoscopic mobilization of the intended gastric conduit and the third is the cervical anastomosis. The patient is then anaesthetised in the usual fashion and double lumen intubation is performed. The patient is then positioned in the left lateral decubitus position and the right chest is prepared in a sterile fashion. The nasal gastric tube is placed to help with oesophageal immobilization. The field should include the patient's axilla as well as the thoracic spine as port sites may be chosen for this locations. A 10 mm 0 and 30° thoracoscope is used. In the anterior axilla line at approximately the 6th-7th intercostal space the first port is placed and the thoracoscope is introduced. Other ports are directed as necessary to gain full exposure to the oesophagus. Fan retractors are used to retract the lung out of the way. The inferior pulmonary ligament is transected as with the open procedure. The azygous vein and the periesophageal tissue are widely resected. Soft drains and retracting forceps are used to mobilize the oesophagus. With the oesophagus completely freed, drains are placed as with the open thoracotomy procedure.

Either a laparotomy may be performed as with the total esophagectomy by thoracotomy technique or the dissection may be performed by laparoscopy. The laparoscopic technique established multiple abdominal wall ports and creates a gastric tube in the same fashion but it is performed by laparotomy.

The final phase of this procedure is to perform an oblique incision along the anterior border of the sternal colloid mastoid muscle down to the super sternal notch. The vascular structures in the sternalcleidomastoid muscle are retracted laterally and the omohyoid muscle is transected to allow full mobilization. The transverse cervical artery may need to be ligated. Self retaining retractors are voided as they may cause accidental damage to the recurrent laryngeal nerve. If the dissection of the esophagus at the thoracic inlet has been adequate the esophagus should be easily mobilized from the anterior longitudinal ligament of the spine and encircled with a soft rubber drain. The drain then serves as a retractor for further proximal dissection. The oesophagus is then transected at an appropriate level away from the upper esophageal sphincter, yet a sufficient distance away from the primary tumour, usually approximately 10 cm to avoid skip metastases or longitudinal lymphatic spread with the resultant tumour at the transection site. Mobilization of the stomach and subsequent anastomosis is performed as described in the section which discusses the transthoracic thoracotomy.

The most recent studies reporting on thoracoscopic eosphagectomy indicate an operative mortality between 5.5-13.5%. The morbidity has been reported to be anywhere from 35-60%. Major causes of complications include respiratory complications, anastomotic leak, and laryngeal nerve injury.

At present there is no advantage to using this procedure over open surgical procedures.