Minimally invasive Ivor Lewis esophagectomy for cancer

Minimally invasive Ivor Lewis esophagectomy is technically challenging but feasible in experienced minimally invasive surgery centers. This video illustrates the surgical approach of an Ivor-Lewis esophagectomy. This surgery was carried out in a patient presenting with a type 2 cardia tumor according to Siewert’s classification. The preoperative workup confirmed the presence of an adenocarcinoma with locoregional lymph nodes. After neoadjuvant chemotherapy, a massive melt of the tumor was evidenced without any residual lesion or any local or distant metastasis. In this context, a curative resection has been proposed. Considering the tumor’s type, a resection combining an abdominal with a thoracic approach was decided upon.

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Minimally invasive Ivor Lewis esophagectomy for cancer

Authors

B Dallemagne, J Marescaux

Abstract

Minimally invasive Ivor Lewis esophagectomy is technically challenging but feasible in experienced minimally invasive surgery centers. This video illustrates the surgical approach of an Ivor-Lewis esophagectomy. This surgery was carried out in a patient presenting with a type 2 cardia tumor according to Siewert’s classification. The preoperative workup confirmed the presence of an adenocarcinoma with locoregional lymph nodes. After neoadjuvant chemotherapy, a massive melt of the tumor was evidenced without any residual lesion or any local or distant metastasis. In this context, a curative resection has been proposed. Considering the tumor’s type, a resection combining an abdominal with a thoracic approach was decided upon.

Mots-clés

Ivor Lewis, cancer, esophagectomy, thoracoscopy, gastric conduit

Type de vidéo

Vidéo chirurgicale

Durée

27'00''

Publication

2010-07

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Jul 2010;10(07).
URL: http://www.websurg.com/doi-vd01en3007.htm

Minimally invasive Ivor Lewis esophagectomy for cancer

1. Clinical case presentation 00'10''

This video illustrates the surgical approach of an Ivor-Lewis esophagectomy. This surgery was carried out in a patient presenting with a type 2 cardia tumor according to Siewert’s classification. The preoperative workup confirmed the presence of an adenocarcinoma with locoregional lymph nodes. After neoadjuvant chemotherapy, a massive melt of the tumor was evidenced without any residual lesion or any local or distant metastasis. In this context, a curative resection has been proposed. Considering the tumor’s type, a resection combining an abdominal with a thoracic approach was decided upon. A primary laparoscopic technique is initiated with a conventional port placement to approach the upper quadrant of the abdomen.

2. Abdominal approach: peritoneal cavity exploration 01'00''

The procedure starts with the exploration of the peritoneal cavity to rule out any lesion that might not have been detected by conventional imaging studies. The first part of the procedure will consist in performing a gastrolysis as the stomach will be used as a substitute to the esophagus.

3. Gastrolysis 01'34''

The gastrolysis is carried out using the Ligasure® vessel-sealing device, which allows for a rapid cauterization and division, especially in a fairly adipose patient. Obviously, the gastrolysis should preserve the vascularization of the greater curvature of the stomach and of the gastro-omental vascular network. The short gastric vessels are divided on their splenic aspect in order to preserve the small vascular network to be found at the cranial portion of the gastric fundus. The gastrophrenic ligament is also divided in order to free the upper portion of the gastric fundus and to initiate the intramediastinal dissection.

4. Gastro-omental vessels dissection 02'28''

As soon as the freeing has been performed on the left aspect of the abdomen, the mobilization is extended along the gastro-omental vessels to the right. At this level, a minimal mobilization of the duodenum is carried out without any kocherization in order to facilitate the cephalic lifting of the gastric tube later on in the procedure.

5. Posterior adhesions dissection 02'56''

Posterior gastric adhesions are also taken down as they will allow to increase the mobility of the gastric tube. Caution must be taken during this maneuver in order to avoid any injury to the right gastro-omental artery, which ensures the vascularization of the gastric tube. Manipulation and exposure are made possible by forceps placed in each hypochondrium and held by the assistants. The surgeon uses the two ports that are placed in the right and left paramedian space. The superior border of the pancreas is approached. The gastric vessels are identified, dissected and divided separately.

6. Lymphadenectomy 03'57''

The lymphadenectomy will be then continued towards the crura of the diaphragm in order to ensure an adequate lymphatic clearance of the entire region comprising the left gastric artery and the posterior peritoneum towards the diaphragmatic orifice. At this level, the use of a Ligasure® device proves comfortable since it must be noted that, in adipose patients, cauterization and division capabilities are perfectly appropriate as compared to conventional techniques using the hook or coagulating scissors.

7. Hiatal orifice dissection 04'41''

The crura of the diaphragm are identified and the dissection is extended on to the hiatal or diaphragmatic orifice in order to initiate the mobilization of the intramediastinal esophagus. The lesser omentum is divided on its hepatic aspect. The phreno-esophageal ligament is then opened on the relief of the right crus, hence giving access to the lower mediastinum. At this level, the lymphadenectomy is respected. In this patient, the results of the neoadjuvant chemotherapy are such that no tumor can be palpated at the level of the cardia. Macroscopically, there is no suspicious lymph node lesion. Nevertheless, the lymphadenectomy is extended until the pre-aortic plane and laterally until the right and left pleura. The mediastinal orifice is enlarged through a division in order to facilitate the cranial lifting of the gastric tube that will be performed subsequently. The right pleura is not opened at this stage of the procedure in order to maintain an adequate pneumoperitoneum. The left pleura is respected. The intramediastinal mobilization is extended until the pulmonary veins. It will be relayed during the thoracic approach.

8. Gastric conduit preparation 07'08''

Next, the gastric conduit is prepared. The lesser curvature of the stomach is prepared about 5 to 6cm proximally to the pylorus. This allows for a satisfying lymph node curettage at this level. Successive firings of the Endo-GIA linear stapler, blue cartridge, are performed in order to create a 5 to 6cm-diameter gastric tube. The gastric conduit will be re-anchored to the proximal portion of the stomach. But, before this maneuver is performed, a running suture is placed on the stapling line in order to reinforce the hemostasis and prevent any leakage. The risks of fistulas are relatively important, especially at the crossing points where the Endo-GIA linear stapler was applied. Generally speaking, our preference is to perform a running suture over the entire length of the gastric tube. Therefore, this gastric conduit is anchored to the proximal portion of the stomach in order to guide its cranial lifting in the mediastinum during the thoracic approach of the procedure. A feeding jejunostomy is placed as enteral feeding is resumed from postoperative day 1.

9. Change of patient position and thoracic approach 09'15''

Next, the patient is placed in a left lateral decubitus position. Four ports are placed in the right thorax. A 5mm, 30 degree scope is used. The pleural incision that has been performed during the laparoscopic approach can be observed.

10. Mediastinal dissection 09'45''

The dissection will be continued at the mediastinum using a conventional lymphadenectomy without resecting the intercostal veins or the azygous vein. The dissection is performed using the Ligasure® device. The right lung has been excluded. The azygous vein is perfectly identified. An umbilical tape is passed around the esophagus in order to facilitate the esophageal dissection. This trick is used to suspend the esophagus as the dissection is continued. A partial exclusion of the right lung can be noted in these pictures. This exclusion will not hinder the completion of this conventional surgery. The right pulmonary veins and arteries and the right bronchus are identified throughout the dissection.

11. Azygous vein dissection 11'27''

The arch of the azygous vein will be dissected. It may be divided by applying a vascular Endo-GIA linear stapler. In this patient, a suture reinforced by clips, which is much safer, was decided upon. The right bronchus is visualized and respected. The membranous portion of the bronchus should always be respected throughout the entire dissection. It is essential to use this technology in order to avoid thermal injuries that could induce secondary fistulas.

12. Proximal esophagus dissection 13'00''

The proximal portion of the esophagus is isolated and identified.

13. Thoracic placement of gastric conduit 13'10''

The gastric conduit is pulled towards the thoracic cavity by placing traction on the proximal stomach and on the gastric tube itself. During this maneuver, it is essential to achieve an appropriate orientation of this gastric tube, which is provided by the position of the staple line situated on the lesser curvature of the stomach. The gastric conduit is freed from the gastric stump.

14. Esophagus division 13'50''

The esophagus will be divided by the Endo-GIA, which has been introduced through a 12mm port placed in the 8th right intercostal space.

15. Anvil introduction 14'20''

During this operative step, the anvil of a 25mm circular stapler is introduced orally. It is attached to a gastric tube according to the conventional technique used for gastric bypass procedures. The introductory gastric tube is freed. The gastric conduit is positioned in contact to the esophageal stump. A short gastrotomy is carried out on the lateral aspect of this gastric conduit. The operative specimen is placed into an Endobag.

16. Stapler introduction via mini-thoracotomy 15'11''

It will be extracted through a short thoracotomy in the 8th intercostal space. The ribs will not be divided. This short incision will also allow to introduce the stapler in order to perform an end-to-side anastomosis.

17. Anastomosis 15'41''

A 25mm-diameter stapleris used. The anastomosis is performed conventionally. The gastrotomy that has been performed for the introduction of the EEA stapler will be closed and divided by another Endo-GIA firing.Before doing so, a visual control is undertaken to check the bringing-down of the nasogastric tube. The Endo-GIA linear stapler is applied in order to close the gastrotomy used for the introduction of the EEA stapler.

18. Gastric conduit fixation 16'49''

The anastomosis is controlled. Three fixation stitches will suture the gastric tube to the pre-vertebral fascia in order to reduce the traction exerted on the anastomosis. The hiatal defect will also be sutured again in order to fix the gastric conduit adequately and to recalibrate the hiatal defect. The stitches are applied between the diaphragmatic muscles and the gastric tube. At the end of the procedure, a 24 French pleural catheter is placed under visual control. On postoperative day 4, a radiological control using gastrograffin will help to confirm the adequacy and the patency of the surgical construction. Fistulas and/or leaks are ruled out. The gastric emptying proves satisfactory despitethe absence of pyloromyotomy. The pathological examination confirms the absence of a residual tumor and of lymph nodes in the resected specimen. Therefore, neoadjuvant chemotherapy has proved successful and effective. However, three additional chemotherapy courses will be proposed to the patient. Radiotherapy is not envisaged.