Thoracolaparoscopic Ivor Lewis Esophagogastrectomy with a Handsewn Anastomosis in Prone Position

Background: With increasing enthusiasm for minimally invasive esophagectomy, a laparoscopic and thoracoscopic Ivor Lewis esophagogastrectomy with intrathoracic anastomosis is performed when at all possible. Circular stapler is usually used in order to create the intrathoracic anastomosis. We report a completely thoracoscopic handsewn double-layer esophagogastrostomy, realized with the patient in prone position, during a thoracolaparoscopic Ivor Lewis esophagogastrectomy.
Method: A 51 years-old man consulted for complete dysphagia associated to weight loss. A barium swallow evidenced a sliding hiatal hernia and a lumen defect of the lower third of the esophagus. Gastroscopy showed the presence of a suspect lesion at 30 cm. Endoscopic ultrasound evidenced a 35 x 16 mm lesion, with irregular margins, and the absence of mediastinal lymph nodes (stage: T2N0). Biopsy showed characteristics of adenocarcinoma. CT-scan confirmed both the presence of the esophageal mass and the absence of lymph nodes. General anaesthesia and double-lumen endotracheal tube intubation were used. First the patient was placed in supine position, and 5 abdominal trocars were placed. Celiac lymphadenectomy started with skeletonization of the hepatic artery until the root of left gastric artery was reached. The left gastric artery and vein were sectioned. A wide Kocher maneuver as well as pyloroplasty were performed. The distal esophagus was dissected up until the level of the inferior pulmonary vein. Polar gastrectomy was performed by multiple applications of a linear stapler blue load, from the crow’s foot medially to the greater curve laterally. The upper part of the gastric remnant was anchored to a penrose and advanced through the hiatus into the right chest. Subsequently the patient was placed in prone position. Three trocars (two 5-mm and one 10-mm) were placed on the posterior axillary line in the 5th, 7th, and 9th right intercostal space. The middle and lower esophagus were dissected. Mediastinal lymphadenectomy with en-bloc resection of the left inferior mediastinal pleura was performed. The azygos vein was ligated and sectioned. The mid-esophagus was transected by scissors just at the level of the azygos vein, and the stomach was well placed into the chest. A completely thoracoscopic handsewn double-layer anastomosis was performed using PDS 2/0 (external layer) and Maxon 3/0 (internal layer) running sutures. A chest tube was left in the pleural cavity. Finally the patient was re-placed in supine position in order to retrieve the specimen in a plastic bag through a suprapubic incision. The intraabdominal stomach was fixed to the hiatus, and a drain was left through the latter.
Results: Total operative time was 340 minutes and blood loss was 150 ml for laparoscopy and 20 ml for thoracoscopy. The patient had an uneventful recovery; the gastrograffin swallow on the 4th postoperative day showed a good passage through the anastomosis and absence of leak. The patient was discharged on the 6th postoperative day. Pathologic report confirmed the adenocarcinoma of the esophagus (stage: pT2bN1Mx).
Conclusions: Thoracoscopy in prone position permits to surgeon to operate in an ergonomic position, and to perform a completely thoracoscopic handsewn anastomosis, without selective lung desufflation. Thanks to this anastomosis the risk of postoperative leak can be reduced, and the hospital stay and patient’s comfort appeared improved.

Session: Podium Video Presentation

Program Number: V012

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