clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

After proximal transection of the esophagus at the level of the aortic arch, the left recurrent nerve nodes (left paratracheal nodes) are removed. The middle mediastinal nodes, comprising the infra-aortic, infracarinal, and periesophageal nodes, are cleared in conjunction with the esophagus.

This exposes the main bronchus, the left pulmonary artery, branches of the vagus nerve, and the pericardium. Both pulmonary branches of the bilateral vagus nerves and the left bronchial artery originating from the descending aorta near the left pulmonary hilum are preserved. However, the esophageal branches of the vagus nerves are severed, and the thoracic duct is also removed together with the esophagus.

A T-shaped neck incision is made and the sternothyroid, sternohyoid and sternomastoid muscles are divided to the clavicular head and the omohyoid muscle is incised at its fascia. After identification of the recurrent nerve, lymph nodes along this nerve (which are in continuity with the nodes previously dissected out in the superior mediastinum) are dissected. The inferior thyroid arteries are then ligated and divided. The paraesophageal nodes, including the recurrent nerve nodes at the cervicothoracic junction, are classified as either cervical or upper mediastinal nodes, according to their position relative to the bifurcation of the right common carotid and right subclavian arteries.

The jugular vein, common carotid artery, and vagus nerve are subsequently identified and divided. On the lateral side, after careful preservation of the accessory nerve, lymph nodes situated lateral to the internal jugular vein are removed. The thyrocervical trunk and its branches and the phrenic nerve are then identified. In this procedure, the cervical nodes (internal jugular nodes below the level of the cricoid cartilage, supraclavicular nodes, and cervical paraesophageal nodes) are cleared bilaterally (arrow indicates the direction of lymphadenectomy).

See transhiatal approach for standard postoperative investigations and complications.

■A better exposure of the upper mediastinum requires transection of the medial head of the sternocleidomastoid muscle and/or partial upper sternotomy.

Minimally Invasive Esophagectomy

Rudolf Bumm, Hubertus Feussner

Introduction

The availability of modern laparoscopic and thoracoscopic techniques as well as videoendoscopy has promoted the development of techniques for minimally invasive esophagectomy. In principle, two techniques have been established and clinically evaluated so far. Thoracoscopic esophagectomy is, in theory, an analog procedure for transthoracic en-bloc esophagectomy, but is in use in only a few centers because it is technically demanding, requires single lung ventilation over extended time periods and has not shown, clinical benefits over conventional open esophagectomy in larger series so far. Radical transhiatal esophagectomy with mediastinoscopic dissection of the esophagus (endodissection) was established in 1990 by Buess and coworkers and clinically tested in our own institution. The method is feasible and safe, and endodissection allows for mobilization of the proximal thoracic esophagus under direct vision and enables mediastinoscopic lymph node sampling and reduces periand postoperative complications compared to conventional transhiatal esophagectomy.

Thoracoscopic Esophagectomy

Indications and Contraindications

Preoperative Investigations/Preparation for the Procedure

(Re-)endoscopy and (re-)biopsy

Procedures

The mediastinal pleura is divided and the entire thoracic esophagus is exposed in a way that the azygos vein is preserved. Then the inferior pulmonary ligament is divided to the level of the inferior pulmonary vein. A silicone drain is placed around the distal esophagus to facilitate traction and exposure, and ultrasonic shears are used for dissection of the peri-esophageal tissues, which should remain attached en bloc to the specimen. The thoracic duct should be sutured with non-resorbable material in order to reduce the risk of chylothorax, and direct vessels from the aorta should be clipped to avoid rebleeding.