Abdominothoracic esophageal resection according to Ivor Lewis with intrathoracic anastomosis : standardized totally minimally invasive technique

Abstract

The clinical and scientific interest in minimally invasive techniques for esophagectomy (MIE) are increasing; however, the intrathoracic esophagogastric anastomosis remains a surgical challenge and lacks standardization. Surgeons either transpose the anastomosis to the cervical region or perform hybrid thoracotomy for stapler access. This article reports technical details and early experiences with a completely laparoscopic-thoracoscopic approach for Ivor Lewis esophagectomy without additional thoracotomy. The extent of radical dissection follows clinical guidelines. Laparoscopy is performed with the patient in a beach chair position and thoracoscopy in a left lateral decubitus position using single lung ventilation. The anvil of the circular stapler is placed transorally into the esophageal stump. The specimen and gastric conduit are exteriorized through a subcostal rectus muscle split incision. The stapler body is placed into the gastric conduit and both are advanced through the abdominal mini-incision transhiatally into the right thoracic cavity, where the anastomosis is constructed. Data were collected prospectively and analyzed retrospectively. A total of 23 non-selected consecutive patients (mean age 69 years, range 46-80 years) with adenocarcinoma (n = 19) or squamous cell carcinoma (n = 4) were surgically treated between June 2010 and July 2013. Neoadjuvant therapy was performed in 15 patients resulting in 10 partial and 4 complete remissions. There were no technical complications and no conversions. Mean operative time was 305min (range 220-441min). The median lymph node count was 16 (range 4-42). An R0 resection was achieved in 91 % of patients and 3 anastomotic leaks occurred which were successfully managed endoscopically. There were no postoperative deaths. The intrathoracic esophagogastric anastomosis during minimally invasive Ivor Lewis esophagectomy can be constructed in a standardized fashion without an additional thoracotomy. Reduction of surgical morbidity remains the highest priority.