Minimal access esophagectomy: Review of technique

Minimal access esophagectomy ISSN: 2394-0026 (P)Original Research Article ISSN: 2394-0034 (O)Minimal access esophagectomy: Review of technique KB Galketiya1*, MVG Pinto21Consultant surgeon, Department of Surgery, Faculty of medicine, University of Peradeniya, Sri Lanka2Consultant anesthetist, Department of Anesthesia, Faculty of medicine, University of Peradeniya, Sri Lanka *Corresponding author email: [email protected] to cite this article: KB Galketiya, MVG Pinto. Minimal access esophagectomy: Review oftechnique. IAIM, 2015; 2(2): 1-7. Available online at www.iaimjournal.comReceived on: 26-12-2014 Accepted on: 06-01-2015AbstractMinimal access esophagectomy reduces the post-operative morbidity associated with openprocedure. We presented our technique which includes using double lung ventilation and acapnothorax to collapse the lung and using an adopted prone position for thoracoscopicmobilization.Key wordsEsophagectomy, Thoracoscopy, Laparoscopy.Introduction complications. To minimize this transhiatal blunt esophagectomy was introduced by Orringer; theEsophagectomy is the surgical treatment for esophagus being mobilized through the hiatusresectable esophageal carcinoma [1, 8]. There is without vision. Even though thoracotomy isa significant morbidity and mortality [1, 8]. It taken away there is a risk of hemorrhage andmay be done with a thoracotomy and a the resection may be inadequate and will notlaparotomy with an intra thoracic anastomosis; allow any lymph node clearance [1, 8]. Minimaltwo stage esophagectomy. In three stage access esophagectomy allows the procedure toprocedure the anastomosis is performed in the be done without thoracotomy and laparotomyneck [1]. [1, 2, 3, 4, 5, 6, 7, 8]. The surgical and anesthetic techniques used at our institution are reviewedThoracotomy contributes significantly to the in this article.morbidity. It may lead to many respiratoryInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 1Copy right © 2015, IAIM, All Rights Reserved.

Minimal access esophagectomy ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Material and methods A 30 degree camera was used. The Azygous vein was initially identified, a useful land mark toPatients with resectable carcinoma esophagus identify the anatomy of right hemithorax.were treated with minimal access Mobilization of the esophagus was performedesophagectomy. A three stage procedure by using ultrasound dissector with bipolarthoracoscopy, laparoscopy and a neck incision, diathermy assisting dissection. Use of bipolarwas done in a majority. In few with tumors close augments hemostais and allowed less use ofto gastro-esophageal junction, laparoscopy and ultrasonic dissector. Sucker was usedtranshiatal mobilization of esophagus under occasionally for blunt dissection. The Azygousvisual guidance of camera was performed. vein was ligated and divided and clips used to reinforce. Dissection enabled clear identificationAll patients planned for surgery were assessed of the trachea and its bifurcation. The lymphfor fitness in the anesthetic clinic. They were nodes visualized were harvested en-block. Afterdone under general anesthesia and complete mobilization, inter costal drain wasendotracheal intubation. placed and the lung expansion was confirmed visually with the camera.Thoracoscopy The patient was positioned supine and theThe ipsilateral lung was collapsed to obtain monitor on the left side at head end. Surgeonspace for dissection. This was done by using a stands in between the abducted legs. Adouble lumen tube and isolated ventilation of pneumoperitoneum of 14 mmHg was created bythe opposite lung at the beginning of the series. verres needle technique using CO2.Later all were performed while ventilating bothlungs with a lung collapse by using a Five ports were used.capnothorax at a pressure of 6-8 mmHg. • Camera port – 10 mm; 1 cm above and to the left of mid lineThe collapsed lung was allowed to fall away • Epigastric port – 5 mm; entry to the leftfrom the posterior mediastinum by positioning of faciform ligamentthe patient in an adopted prone position; • Left hand working – 5 mm; in betweenpatient was placed semi prone and a near prone camera and epigastric ports just to rightposition was obtained by tilting the table. of midlineMonitor was placed on the left side and surgical • Right hand working – 10 mm; midteam positioned right side. clavicular at the level of camera port. A 10 to 5 mm reducer was used for 5mmThree ports were used instruments and used at 10 mm for clip • 10 mm camera port - 7th inter costal applicator. space, below the inferior angle of the • Retraction port – 5 mm; anterior scapula in the posterior axillary line axillary, parallel to left hand working • 10 mm right hand working port - 5th port inter costal space, mid axillary line • 5 mm left hand working port - 9th inter The head end was elevated by about 30 degrees costal space, mid axillary line and tilted towards the right side. The left lobe of the liver was retracted with a fan retractor, fundus pulled back with the retraction port andInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 2Copy right © 2015, IAIM, All Rights Reserved.

Minimal access esophagectomy ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)hiatal dissection performed using bipolar neck and at the gasto-esophageal junction fordiathermy and ultrasonic dissector. The chest is removal of the specimen. A single layernot entered at this stage as it will cause a loss of interrupted anastomosis was performed.pneumothorax. The left gastric artery and vein However, some patients developed gastricwere dissected in some. When the vessels don’t dilatation with persistently high naso-gastricstand out well complete dissection was done aspiration that necessitated a change oflater. Bipolar diathermy was used on the left technique. The cervical esophagus wasgastric vessels which facilitate standard clips to transected and a naso-gastric tube tied to thebe applied. Subsequent division was done by distal esophagus. A mini-laparotomy wasscissor. The stomach was held up with a babcock performed for delivery of the mobilized stomachforceps via the epigastric port and division of and esophagus. The esophagus was divided atgastro-colic and gastro-splenic ligaments were the gastro-esophageal junction and a gastricperformed. The right gastro-epiploic vessels tube constructed after excision of the lesserwere identified and preserved whilst the short curve. A pyloromyotomy was performed. Thegastric are divided. The gastro-colic was divided gastric tube was pulled in to the neck towith ultrasonic dissector and bipolar diathermy complete the esophago-gastric anastomosis. Aand ultra-sonic dissector were used for the short feeding jejunostomy was sited early in thegastric vessels. Once the stomach was fully series. Drains were not placed in the abdomenmobilized dissection was carried out through the and neck.diaphragmatic hiatus. The left crus of thediaphragm were partially divided with ultra- The following parameters were monitoredsonic dissector. during surgery.Transhiatal oesophagectomy • Pulse rate, blood pressure, centralThe mobilization of the stomach was performed venous pressurelaparoscopically. The left diaphragmatic cruswas partly divided and the mobilization of the • Oxygen saturationesophagus was carried out in the chest through • Urine out putthe hiatus. Fan retractor through the epigastric • Fluid balanceport and a probe through the retraction port • Body temperaturewere pushed in through the hiatus to obtain • Irrigation fluid usedspace. The insufflated CO2 also helped to create • CO2 volumes usedspace to allow the telescope and the dissectinginstruments to be pushed in gradually in to the The pressure within the chest and abdomen haschest. Bipolar diathermy and blunt dissection detrimental effects on ventilation and cardiacwith the sucker were the main way of dissection. output which is compounded by the lungScissor was used to divide thick tissue following collapse during thoracoscopy. There is anbipolar quatery. increased load of CO2.The ventilatory management were adjusted to keep safeThe cervical esophagus was mobilized by open oxygenation and to increased co2 load. Theaccess from left side of neck. Early in the series, central venous pressure was noted to rise bypatients who had thoraco-laparoscopic about 5cm H2O with introduction ofmobilization, the stomach was pulled up to the pneumothorax or pneumoperitoneum. This wasneck incision. The esophagus was divided at the taken in to consideration in the fluid management. All patients were extubated and transferred to the intensive care unit.International Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 3Copy right © 2015, IAIM, All Rights Reserved.

Minimal access esophagectomy ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)Results temperature drops were not significant in spite of prolonged operating time, use of co2 andTotal 30 patients were operated out of which 26 irrigation fluid. The temperature drop was lessthoraco-laparoscopic and 4 transhiatal. Per compared to open procedures, probably due tooperative data were as per Table – 1. The less exposure of body cavities.respiratory and cardio-vascular parameters werestable. There was a drop of temperature by 0.5- The blood losses were minimal. Combination of0.7 ˚C. ultra-sonic dissector and bipolar diathermy allowed a dissection with good hemostasis. ThePost-operative outcome were as per Table – vessels which required suture ligation and/ or2.There were anastomotic leaks in three were azygous vein and left gastric pedicle. Allpatients. Two settled with conservative other vessels were controlled with bipolarmanagement by nil by mouth and naso-gastric diathermy and ultra-sonic dissector.feeding. The other patient developed apneumonia required re-intubation and died on Mobilization of the thoracic esophagus is lessthe 21st post-operative day. The oxygen challenging than laparoscopic mobilization ofdependency was less in the patients who stomach. This is because esophagus has nounderwent transhiatal esophagectomy; they had major vascular supply to control and thebetter respiratory efforts, had less X-ray changes anatomical relationships are more or less in onein the chest, when compared to thoracoscopy plane without any major attachments togroup. Another patient in the thoracoscopy surrounding viscera. At the early phase of thegroup developed a pneumonia required re- learning curve, unless assisted by a surgeon whointubation and died on the 18th day. is experienced, it may be advisable to perform the thoracoscopy and mobilize the stomach byHistopathology results laparotomy. This hybrid procedure will help toAll had clear resection margins. The lymph node reduce operating time and esophagealharvest ranged from 12 to 16 in thoracoscopic mobilization can be completed by transhiataland transhiatal groups. blunt dissection at laparotomy [9]. To embark on video assisted transhiatal oesophagectomy oneDiscussion has to be competent in laparoscopic mobilization of the stomach. In addition to workThoraco-laparoscopic oesophagectomy allows in close space through the hiatus is challenging.oesophagectomy through minimal incisions inthe chest and abdomen. The post-operative pain With experience operating times can be welland the requirement for strong analgesics is less compared to open surgery. Lack of opening andallowing early mobilization [1, 2, 3, 4, 5, 6, 7, 8]. closing times is an advantage. Transhiatal procedure has the advantage of working only inOther observed advantages were clear vision the supine position saving the time spent forprovided by a magnified view allowing a precise position changing in the thoraco-laparoscopicdissection. There is minimal exposure of body procedure.cavities to exterior, absence of strong retractionof incisions and less handling of other viscera. Usually thoracoscopic procedures are done withThis too adds to less pain and ileus. The a lung collapse using a double lumen tube or a bronchial blocker. For ideal setting a flexibleInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 4Copy right © 2015, IAIM, All Rights Reserved.

Minimal access esophagectomy ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)bronchoscope is required. There is a extended lymphadenectomy, which harvestdocumented failure rate and complications. We about 30 nodes [1].have successfully performed the surgeryventilating with a single lumen tube. The lung Conclusioncollapse was achieved by creating acapnothorax. The lung collapse was satisfactory A step wise progression through thoracoscopy[3, 10, 11]. We have studied the safe and and laparotomy to thoraco-laparoscopyeffective pressure for a wide range of facilitates overcoming a new learning curve.thoracoscopic procedures and found to be 6-8 Using an adopted prone position by placing themmHg [12]. patient semi-prone and a table tilt was equally effective to full prone position. Effective lungThe favored position for posterior mediastinal collapse was obtained by double lung ventilationprocedures is prone. This allows the collapsed and a capnothorax of 6-8 mmHg. Laparoscopiclung to fall away from the field of dissection [1, transhiatal mobilization allowed a shorter4, 5, 6, 7]. Positioning prone takes time and has operating time and the post-operative morbiditynoted complications [13]. If conversion to was less than in the thoracoscopy group. A jointthoracotomy is required, as in face of anesthetic and surgical effort helped safehemorrhage, changing to lateral position will completion and recovery of the patients.take time. We evaluated the adopted proneposition described in the method. This position Referencesis easy to achieve devoid of main complicationsof a full prone position and easy change to 1. Joris J G Scheepers, Donald L van derlateral position is possible by tilting the table. Peet, Alexander A F A Veenhof, Miguel AThe adopted prone position allowed the Cuesta. Thoracoscopic resection forcollapsed lung to fall away adequately [3, 14, esophageal cancer: A review of15]. literature. J Minim Access Surg., 2007; 3(4): 149–160.In the patients undergoing thoracoscopicmobilization there were more respiratory 2. Shi-ping Luh, Hui-ping Liu. Video-complications than the transhiatal mobilization, assisted thoracic surgery―the past,well explained by not having any degree of lung present status and the future. J Zhejiangcollapse in the latter. The hospital stay was not Univ Sci B., 2006; 7(2): 118–128.reduced explained by various reasons; eventhough incision size is small the complexity of 3. Galketiya KB, PintoV, SM Bandara.the dissection necessitates time for recovery. Thoracoscopy: Beyond the key hole. TheMost of the patients being nutritionally depleted Sri lankan Journal of Surgery, 2014;prior to surgery also delays recovery [3]. 32(1): 29-34.Pathological clearance with clear resection 4. Dapri G, Himpens J, Cadière GB. Robot-margins was obtained. The lymph node harvest assisted thoracoscopic esophagectomywas comparable in thoracoscopic and with the patient in the prone position. Jtranshiatal approaches, which ranged from 12 to Laparoendosc Adv Surg Tech A., 2006;16. This is less compared to series published on 16(3): 278-85. 5. Nguyen NT, Roberts P, Follette DM, Rivers R, Wolfe BM. Thoracoscopic and laparoscopic esophagectomy for benignInternational Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 5Copy right © 2015, IAIM, All Rights Reserved.

Minimal access esophagectomy ISSN: 2394-0026 (P) ISSN: 2394-0034 (O)and malignant disease: lessons learned 11. V Pinto, Perera R, Galketiya KB. Thoracoscopic sympathectomy, can it befrom 46 consecutive procedures. J Am performed safely while ventilating both lungs. Annual academic sessions collegeColl Surg, 2003; 197: 902-13. of surgeons of Sri Lanka, 2012. 12. V Pinto, K Galketiya. Insufflation6. Collard JM. Role of video assisted pressure required for thoracoscopic surgery and its influence on respiratorysurgery in the treatment of oesophageal and cardiovascular parameters. Sri Lankan journal of anaesthesiology, 2014;cancer. Ann Chir Gynaecol, 1995; 84: 22(2): 55-58. 13. Edgcombe H, Carter K, Yarrow S.209-14. Anaesthesia in the prone position Br. J. Anaesth., 2008; 100(2): 165-183.7. McAnena OJ, Rogers L, William NS. Right 14. Galketiya KB, Wickramanayake AB. Minimal access to the mediastinum;thoracoscopically assisted assessment of camera port placement and patient positioning. Galle medicaloesophagectomy for cancer. Br J Surg, Journal, 2009; 14: 107. 15. Galketiya KB, Pinto V, Perera R.1994; 81: 236-8. Thoracoscopic oesophagectomy - Is semi prone position acceptable. Annual8. Palanivelu C. Minimally invasive surgery academic sessions college of surgeons of Sri Lanka, 2012.in oesophageal carcinoma-currentconcepts. Art of laparoscopic surgery,Jaypee, 2007; p. 393.9. Galketiya KB, Edirimuni SS, MuthumalaMinimal access oesophagectomy;thoracoscopy or thoraco-laparoscopy.Annual academic sessions college ofsurgeons of Sri Lanka, 2007.10. Pinto V, Perera R, Galketiya KB,Jayasooriya U, Wickramasinghe WAAP.“Tension under tension”-our experiencein the use of single lung Vs both lungventilation in thoracoscopic majorsurgery. Annual academic sessions ofThe College of Anaesthesiologists of SriLanka, 2013.Source of support: Nil Conflict of interest: None declared.International Archives of Integrated Medicine, Vol. 2, Issue 2, February, 2015. Page 6Copy right © 2015, IAIM, All Rights Reserved.