How I Teach It: Minimally Invasive Esophagectomy

Abstract

In this era of new and emerging technology, surgical procedures evolve at an astounding pace. The minimally invasive esophagectomy is no exception. This article, and accompanying video, focus on technical steps involved and the elements crucial for teaching residents and peers a minimally invasive esophagectomy. Teamwork and good communication play a major role in maintaining patient safety but also have significant impact on the teaching and learning experience. The aim of this article is to review the teaching steps of minimally invasive Ivor-Lewis esophagectomy. It is important to consider there are technical differences between surgeon and that we learn from each other.

Introduction

The first successful esophagectomy was in 1933 by Dr Grey Turney, by transhiatal approach. The minimally invasive esophagectomy with intra-thoracic anastomosis owes its origins to Dr Ivor-Lewis, who did the first thoracic esophageal resection in 1945. ¹ With the evolution of surgical technique the Ivor-Lewis approach has moved from open laparotomy and open right thoracotomy to be completely minimally invasive or robotic. The same principles apply today and the same aims of the surgery.

In this video we focus on the technical steps involved in a minimally invasive Ivor-Lewis esophagectomy. This surgery’s outcomes are dependent on good teamwork and the collaborative efforts between surgeons and anesthetists.

Perioperative technical aspects are very sensitive in this surgery and can significantly impact its duration and the patient’s outcome. Everybody’s comprehension of the procedure is crucial for its success. For this reason, I teach to surgical residents or fellows and to anesthetist residents or fellows when I do this surgery.

Technical Aspect of Intubation and Positioning

For a long surgery such as a minimally invasive esophagectomy, patient pressure point, and surgeon position can lead to injuries. Resident involvement in patient positioning is very important. This ensures that they learn how to prevent injuries and promote surgical ergonomics.

The abdominal portion is done in lithotomy position with a single lumen endotracheal tube. I use Nissen straps to stabilize the patient’s legs. It is important to keep the patients knees in the shoulder axe, it prevents injury and allow us to avoid having our grasper hitting the patient legs. One surgeon is positioned in between the patient’s legs and one surgeon to his left. I use an Airseal^® insufflator with a pressure of 14 mmHg because I don’t have access to a regular laparoscopic insufflator in the thoracic operative room.

The thoracic portion is done in left lateral decubitus. The patient is on a bean bag and I don’t use any insufflator. I had bad experiences with right side bronchial blocker because we usually put traction on the right main bronchus during the esophageal dissection. This caused displacements of the blocker and also ischemia of the posterior membranous portion of the bronchus. For this reason, I only use double lumen tube for intubation.

I use LigaSure™ for the abdominal and thoracic dissection. I prefer this energy device because its jaws don’t get hot and reduces the risk of thermal injury. I also feel safer because it is known to seal 7 mm vessels. ²

Abdominal Step

I start with the abdominal portion of the surgery. It’s easier to teach stomach dissection because resident usually have anatomical references, having done paraesophageal hernia repair and bariatric surgery.

Exposure is key and it starts with trocar positioning. I use 5 trocars and 1 epigastric incision for the Nathanson retractor from Mediflex^®. The 12 mm camera trocar is placed 15 cm below the xyphoid apophysis on the abdominal midline. There’s a 12 mm trocar at the inferior right quadrant to pass the staplers and another 12 mm trocar at the left upper quadrant, just below the coastal margin. The Airseal^® is placed on the left flank and the surgeon left hand is at the right upper quadrant (see the picture in the Supplemental Video).

I teach residents to start with the opening of the gastro-hepatic ligament toward the right crura. Posterior dissection of the hiatus is helpful at this point because it later helps us pass the vascular stapler in position to cut the left gastric vessel at its point of origin from the celiac artery. This enables us to remove all the gastric vessel lymph nodes. I also remove common hepatic nodes and celiac nodes if possible. I teach residents to look at the initial CT-scan so they know where the pathological lymph nodes were before neoadjuvant therapy to ensure we resect all of them. A more extensive lymph node dissection provides a better staging and reduces local recurrence. ³ In benign cases, we omit the lymphadenectomy.

Next comes gastric conduit preparation by opening the gastro-colic ligament. A good understanding of the anatomy is key, particularly in obese patients where the gastro-epiploic vessels are harder to see because surrounding fat tissue. This is the most important step of the surgery because the gastro-epiploic vessel is the only source of vascularization for the conduit. This is by far the most stressful part of the surgery. I should never hold the vessels with an intestinal grasper. All surgeons must be very attentive during the gastric conduit dissection because any mistake can have major consequences for the patient. The presence of an ischemic conduit results in an unsuccessful esophagectomy and the patient may need an esophagostomy and a second surgery.

The easiest way to access the posterior gastric space is through the gastro-colic ligament. Usually, I am able to see the dissection plane immediately next to the transverse colon. After, I dissect the short gastric vessel. This is because it is easier to do while holding the stomach up. I can now put a penrose around the gastro-esophageal junction. When I gain this mobility, it is safer to continue my dissection through the right of the abdomen, up to the pylorus. I always tell the residents to remove all posterior adhesions. When I hold the pylorus with a grasper, I should be able to move it up to the right crura. This is how we know we have dissected enough.

I make a narrow conduit of 3 cm and I mark the stomach with a surgical pen. The idea is to measure an intestinal grasper and use it has a ruler inside the abdomen. I teach the resident to pull hard on the gastric fundus to be able to straighten up the stomach and have a straight conduit. When the stomach is very big and redundant we use a penrose around the antrum to be able to pull it straight. I staple the vessels of the lesser curvature with a vascular load at the incisura angularis. After, I start to build the conduit with a first application of 45 mm intestinal stapler. The conduit is straighter this way. After, we use 60 mm intestinal staplers. I don’t transect the stomach totally in the abdomen, I do it in the chest. I teach residents to always double check with the anesthetist that there is nothing in the esophagus (no nasogastric tube, no feeding tube, no thermometer) before passing the stapler.

I never do pyloromyotomy. If I have doubts that the pylorus isn’t open enough at the end of the case, I inject Botox^®. I know this is subject to diverging opinions, but so far, I have had success with this strategy.

I finish the abdominal part with the hiatal dissection. I prefer to do it at the end to prevent pneumothorax and have better visualization in the abdomen. I voluntarily open the left pleura to put a Blake^® drain. It is less painful for the patient than bilateral chest tube and the patient doesn’t lay on it during the thoracic part. At the end, it’s important to take note of the hiatus defect’s size. If it is big, I put 1 or 2 posterior stitches to prevent paraconduit hernia.

I finish the abdominal part with a jejunostomy. I make a 5 cm mini-laparotomy incision, it is quicker and allows me to do Witzel stiches on the small bowel to prevent leakage. I go for safety, there is a lot of controversy between the use of jejunostomy, nasogastric tube and early per os approach. ⁴ Even if they have their complications, they have significant nutritional benefit.^5-7

Thoracic Step

The thoracic portion is done by right thoracoscopy. We perform a work incision of approximately 4 cm on the anterior seventh or eighth intercostal space and 1 incision of 10 mm in the anterior fourth intercostal space. I also put one 5 mm trocar and one 10 mm trocar in the back aligned with the angulus inferior of the scapula that I then use to dissect the esophagus. The 5 mm trocar is placed as low as possible and the 10 mm trocar immediately below the scapula. The camera will be placed in the ninth intercostal space at the posterior axillary line. If possible, I like to have another resident or medical student holding the camera to free up each surgeon’s hands. This allows each surgeon to have access to the 2 trocars on his side of the patient. I believe that performing this surgery positioned at the patient’s back is easier. The only exception is for intracorporeal stitches of the anastomosis where I prefer to position myself in front of the patient.

I start by opening the right pulmonary ligament and the posterior hilum pleura to allow me to dissect all carinal lymph nodes. I also open the pleura on the back of the esophagus. For benign disease or very early esophageal cancer that cannot have submucosal resection, I only remove the esophagus with the peri-esophageal lymph nodes. For locally advanced esophageal cancer, I usually perform en bloc resection of the esophagus with the azygos vein, and everything in between. I also remove the right paratracheal lymph nodes if it is a middle esophagus cancer. In this video the case was a 5 cm circumferential T1a Adenocarcinoma of the distal esophagus, so I limited my dissection. When dissecting the esophagus, I always teach the residents to look at the different pitfalls. It is important not to injure the left inferior pulmonary vein nor the left main bronchus. I don’t see those structure easily if we don’t pay attention to them.

I always dissect up to the azygos vein and we do our anastomosis between the thoracic outlet and the azygos vein to have the straightest conduit. This step is important to optimize conduit emptying.

I teach residents to do an end-to-side mechanical anastomosis using and 25 mm Transoral Circular Stapler Anvil EEA™ OrVil™. I choose this mechanical anastomosis because it is safe, efficient, and reproducible. ⁸ There is no significant difference in the rate of anastomosis leak and stricture.^9-11 I emphasize the importance of reviewing all the steps with the anesthetist before proceeding with the anastomosis. There are so many things that can go wrong, and you must be prepared. The orogastric catheter should pass through the patient’s mouth and the smooth part of the device should be facing the soft palate. I hold each side of the esophagus and create an opening in the middle with surgical scissors. The orogastric catheter should appear through this hole. I pull it out until we see the metallic part of the transoral circular stapler. I cut the blue stitches and grasp the metallic part with an Anvil grasper. I bought an Anvil grasper to hold the EEA™ OrVil™ because it is much easier to manipulate the device with it since it fits it perfectly. I then open the conduit on the staple line side, just in front of where I will do the anastomosis, to pass the EEA™ stapler. The alignment of the EEA™ OrVil™ with the EEA™ stapler is essential if you want the device to work. There are 2 key factors that you need to check before closing the device: hear the click and make sure the orange line is inside the EEA™ OrVil™. It is a difficult anastomosis and takes time to master. The key is to be patient and to follow the steps.

I remove excess stomach with a 60 mm intestinal stapler. The trick to ensure we have both sides of the stomach is to pass 3-0 silk stitches on both sides to hold them together. It’s also very important to have a minimum of 1 cm of stomach between the linear and circular staple line to decrease the risk of ischemia and leaks. I finish with 3-0 silk stitches between the stomach and the esophagus to decrease the tension on the mechanical anastomosis and reduce the risk of leaks.

At this point I proceed to a gastroscopy to observe our anastomosis and verify that the conduit is straight and the pylorus is open. I put a 18 Fr nasogastric tube in place to decompress the conduit. I also do a leak test, visualizing the anastomosis by thoracoscopy while the gastroscopy is performed.

I keep nasogastric tube up to 7 days post-operative. It is a consensus we have between esophageal surgeons in our center. For the safety of our patient, it is better to trend toward standardization of post-operative care.

I let a 28 Fr chest tube in place before closing that will be remove on post-operative day 1 and a Blake^® drain next to the anastomosis in case we have a leak.

The patient is extubated, and we start early enteral feeding on postoperative day 1.

Conclusion

There are many ways of doing a minimally invasive esophagectomy. I think every surgeon is strongly influenced by their professors. Fortunately, working in a university center also brings influence from the trainees, who add techniques and ideas from other centers or even challenge us with new ways of thinking.

Minimally invasive esophagectomy is a technical surgery. Always doing the same steps is helpful for teaching the residents and patient safety. Repetition is key in mastering this surgery, even if each case is different. It takes time and many cases before residents can perform all the steps of the surgery, and it’s important to understand this so that their enthusiasm doesn’t subside. I believe that it’s helpful to identify each step the residents are supposed to do in each case.

To conclude, the minimally invasive esophagectomy by the Ivor-Lewis technique is a safe technique with excellent postoperative and oncological results. Because this procedure has many risks, it is challenging to learn and to teach. In any case, the feedback between teaching and learning this technique amongst experienced surgeons and those in training is important to maintain the quality of surgical care for patients with pathologies that requires esophagectomy.