Page 47 - WJOLS - Laparoscopic Journal

Sajesh Gopinath
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6. Postoperative pain and opiate analgesic requirements by Collard et al in 1993. These first efforts involved
7. Postoperative morbidity and mortality thoracoscopic esophageal mobilization with subsequent
8. Hospital stay laparotomy for gastric mobilization and cervical anastomosis.
9. Satisfying oncologlcal principle This approach avoids the morbidity of a thoracotomy, and
10.Quality of life analysis. permits complete and thorough mediastinal dissection.
Several groups have reported their experience with excellent
MATERIALS AND METHODS
results using this technique which currently represents the
A literature search was performed using search engines most popular MIE technique. Refinements in the
Google, HighWire Press, SpringerLink, and library facility thoracoscopic technique have been pioneered by Luketich
available at laparoscopic hospital. Criteria for the selection et al 9,10 describing a thoracolaparoscopic esophagectomy.
of papers were upon statistical way of analysis, institute if This technique involves video-assisted thoracoscopic
specialized in laparoscopy, the way of management and esophageal mobilization in complete left lateral decubitus
operative techniques. position followed by supine laparoscopic gastric mobilization
OPERATING TECHNIQUE and preparation of the gastric conduit with a standard cervical
anastomosis. This offers the potential benefit of avoiding
Different surgical techniques are available, and the option the need for both thoracotomy and laparotomy, minimizing
depends on tumor location, extent of lymphadenectomy and pain in the postoperative period, and allowing a more rapid
surgeons’ preference. The two most common open recovery.
techniques are transhiatal and transthoracic (Ivor-Lewis) To facilitate the abdominal procedure, some groups use
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esophagectomies (THEs and TTEs respectively). THE a laparoscopic-assisted hand-port system, providing more
involves a laparotomy, blunt dissection of the thoracic tactile control and potentially decreasing operative time. 15
esophagus, and cervical gastroesophageal anastomosis in
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the left neck. Limitations include inability to perform a Furthermore, a hand-assisted system could be used in the
full thoracic lymphadenectomy and lack of visualization of thoracoscopic phase of the procedure to facilitate exposure
the mid-thoracic esophageal dissection. In contrast, TTE into the right thoracic cavity (hand-assisted laparoscopic
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combines a laparotomy with right thoracotomy and and thoracoscopic surgery). Other modifications to this
intrathoracic anastomosis. This approach allows for wide technique include thoracoscopic mobilization of the
mediastinal lymphadenectomy with direct visualization. esophagus and mediastinal lymphadenectomy in the prone
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Other modifications of the transthoracic approach include position. The main advantages described for prone
a left thoracoabdominal incision, extended 3-field thoracoscopic mobilization of the esophagus are shorter
esophagectomy, and cervical anastomosis. 13 anesthesia time and better postoperative respiratory function
MIE has been explored in both transthoracic and than with the left lateral position.
transhiatal approaches with the goal of overcoming intrinsic A minimally invasive THE was initially described by 7
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limitations. Multiple minimally invasive approaches have been DePaula et al in 1995 and then Swanstrom and Hansen
described that combine thoracoscopic or laparoscopic in 1997 as the first totally laparoscopic esophagectomy.
procedures with various operative positions of the patient The main advantage is direct visualization of lower
and anastomotic techniques (Table 1). mediastinum without blind dissection. Using this technique,
MIEs for the management of esophageal cancer were a laparotomy is avoided. Other modifications to MIE involve
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first described by Cuschieri et al in 1992, and later refined the use of mediastinoscopic methods to aid superior
mediastinal dissection. 18
Table 1: Minimally invasive esophagectomy techniques Some limitations of the laparoscopic THE involve the
instrumentation, narrow field of the mediastinum, and
• Thoracoscopic esophagectomy with laparotomy and cervical
anastomosis two-dimensional view of conventional laparoscopic
• Thoracoscopic esophagectomy with laparotomy and intrathoracic equipment. Robotic systems allow the possibility of
anastomosis
• Thoracoscopic esophagectomy with laparoscopy and cervical overcoming some of these limitations. Some groups have
anastomosis reported their early experience with robotically assisted
• Thoracoscopic esophagectomy with laparoscopy and THE, 20-22 which involves laparoscopic gastric mobilization,
intrathoracic anastomosis
• Laparoscopic gastric mobilization with thoracotomy and mediastinal robotic dissection, and conventional transhiatal
intrathoracic anastomosis dissection from the cervical incision. This technique allows
• Laparoscopic THE with cervical anastomosis three-dimensional visualization, improved magnification, and
• Laparoscopic hand-assisted THE with cervical anastomosis
• Laparoscopic esophagectomy with prone thoracoscopic greater range of instrument motion and could potentially
esophageal mobilization diminish intraoperative complications during esophageal
• Robotically-assisted laparoscopic THE with cervical anastomosis.
dissection in the mediastinum.

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