Page 49 - WJOLS - Laparoscopic Journal

Sajesh Gopinath

is retracted caudally. This exposes the second part of • Conversion rate to open procedures was on an average
duodenum, which is kocherized. 5.6% (0-36%). 9,10,14-42
The left lobe of liver is retracted by the left assistant, • Median ICU stay was 1.5 days (range 0.5-6). 9,10,14-42
and the gastrohepatic ligament is cut. The cut is extended • Median hospital stay was 11.4 days (5.5-31). 9,10,14-42
upward to the lower end of the hiatus. The right crus of the • Median blood loss was 190 ml. 9,10,14-42
diaphragm is identified, and the peritoneum over it is cut. • Postoperative mortality was 2%. 9,10,14-42
This cut is extended up to the hiatus. The dissection is • The over-all complication rate was 41%. 9,10,14-42
continued posteriorly until the left crus is identified. The • Pulmonary complication rate was 20%. 9,10,14-42
esophagus is dissected all around at the level of hiatus. • Anastomotic leaks were reported in 8.7%
All the nodes along the celiac trunk together with the (0-25%). 9,10,14-42
common hepatic, splenic, and left gastric artery are removed. • Vocal cord paralysis occurred in 1.5%. 9,10,14-42
The left gastric artery and vein are clipped and cut. The • Reoperations were reported in 6%, chylothorax 2%,
hiatal opening is then widened. 9,10,14-42
0.8% tracheobronchial tears or necrosis.
Stage 3: Cervicotomy and Esophagogastric • Incidences of splenectomies 0.3% and other visceral
Anastomosis injuries (pancreas, colon) were low. 9,10,14-42
• Oncological outcome of MIE: Median lymph nodes
The patient is placed in the head-up position with the
neck extended and turned toward the right. A left retrieval of all series was 14 nodes. Lower yields were
supraclavicular transverse incision is made. The two heads reported after transhiatal than after transthoracic
of the sternocleidomastoid are separated, exposing the MIE. 9,10,14-42
carotid sheath together with internal jugular vein and • Among the survival rate report studies, 1-year survival
common carotid artery. The inferior thyroid vein is ligated, rate was of a median of 75%. Reported 3-year survival
and the vessels are retracted laterally to reach the prevertebral was 41%. 9,10,14-42
fascia. The esophagus is lifted from its posterior bed, and Operative times, blood loss, transfusion requirements,
the dissection is continued posteriorly until the right lateral ICU and hospital stays were shorter after MIE but without
wall is reached. The esophagus is separated from the trachea any difference in fistula rates. Smithers et al reported the
and completely encircled. largest available series of MIE, comparing 309
Mobilization is confirmed by pulling the esophagus into thoracoscopic-assisted esophagectomies with 23 totally MIE
the neck. The esophagus is divided by placing two stay (laparoscopic and thoracoscopic) and 114 open
sutures. The distal end is tied, and a nasogastric tube is tied esophagectomies during the same time period. Their
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to the distal end. The entire esophagus together with the thoracoscopic resections were found to have marginal
nasogastric tube is pulled through the hiatus laparoscopically. benefits over open resections, such as reduced blood loss
A small abdominal incision is made at the level of camera (400 ml vs 600 ml), transfusion rates (27% vs 37%) and
port. The stomach and esophagus are delivered using a skin one day shorter hospital stay (13 days vs 14 days). The
barrier. An extracorporeal stomach tube is prepared and morbidity profile was similar for all three approaches except
pulled back through the posterior mediastinum into the neck, for a much higher stricture rate of anastomosis after MIE
and an esophagogastric anastomosis is done in two layers. (22% vs 6%). Using a policy of standard mediastinal LND
A feeding jejunostomy is established in all cases. (including periesophageal and subcarinal but not upper
Transhiatal esophagectomy: The esophagus is mobilized mediastinal nodes), Smithers et al retrieved a median of
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en bloc together with the lymph nodes of lower mediastinum 17 lymph nodes. Others have shown that even more extended
through the hiatus after transection of the diaphragm vein.
During the transhiatal dissection, the right and left pleura lymph node dissections can be performed by MIE and lead
must be visible, as well as the aorta dorsally, and the vena to excellent 5-year survival rates above 50%.
cava and pulmonary trunk ventrally. The dissection then is Pulmonary complications are the most frequent source
continued upto the aortic arch. of complications and mortality after an esophagectomy.
Robotically-assisted laparoscopic esophagectomy: Their reduction seems to be one of the aims of any MIE
Robotic technology provides more accuracy, a wider range technique. The main pulmonary complications seen were
of motion through articulated robotic wrists, finer tissue pneumonia, pleural effusion, atelectasis, pulmonary embolism
manipulation capability, and three-dimensional visuali- and assisted ventilation. All were much less in MIE. Other
zation. 20-22 than respiratory complications, the classical complications
of esophagectomy, such as anastomotic leaks and vocal
OUTCOME cord palsy is more in MIE but not significantly high. Risk
• Median operative time was 230 minutes (range of of tracheobronchial injuries thus seems to be increased
medians 180-400 minutes). 9,10,14-42 compared to open resections. 9,10,14-42

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