Pierre Allemann, MD1, Donald van der Peet, MD2, Styliani Mantziari, MD1, Pierre Fournier, MD1, Miguel Cuesta, MD2, Nicolas Demartines, MD, FACS1, Markus Schafer, MD1. 1Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, CH, 2Vrie University Medical Center (VUMC), Amsterdam, NL
Introduction: Ivor Lewis procedure is the mainstay of curative treatment for distal or junctional esophageal cancer. Minimally invasive surgery (MIS) has recently gained more importance as increasing evidence shows clear clinical benefits. Different techniques are concurrently used, combining laparoscopy, video-assisted thoracic surgery or thoracoscopy for hybrid or full minimally invasive procedures. Creation of an intrathoracic anastomosis still represents a critical technical challenge. This video shows a complete minimal invasive esophagectomy, with a particular emphasis on intrathoracic anastomosis.
Methods and procedures: Surgery starts by a 4-ports laparoscopic gastric mobilisation with a radical dissection of the gastro-esophageal junction and lymphadenectomy at the celiac trunk, performed in supine position. The stomach is tubulised, starting 4 cm proximally above pylorus at the lesser curvature, using 4-6 linear staplers. A 2-cm bridge of tissue is kept proximally to pull the tube into the thorax. The patient is then flipped in a prone position. A 4-ports right thoracoscopic approach is used, with CO2 pneumothorax of 8 mmHg without pulmonary exclusion. After esophageal dissection and en-bloc lymphadenectomy, the esophagus is transected at the level of azygos vein. The gastric tube is pulled and cut with a 4-cm esophageal overlap. The esophagus stump is opened in the middle of the staple line, and the gastric tube at its dorsal part. A latero-lateral esophago-gastric anastomosis is constructed using a 30mm linear stapler. Its insertion site is closed using self-locking absorbable 3-0 running sutures. The anastomosis is covered by omental wrap. Finally, the specimen is retrieved through a 4cm incision, protected by a plastic sheet.
Results: Advanced skills in both abdominal and thoracic MIS and experienced team including nurses and anesthesiologists are imperative prerequisites for this type of intervention. The main advantages are: full and wide access to the thoracic cavity, avoidance of selective intubation (both lungs can be ventilated during the whole intervention) and minimized surgical trauma and its related sequels due to the completely minimal invasive approach, without compromising oncological standards.
Conclusion: Complete minimal invasive esophagectomy is the most recent step to optimize clinical outcomes of surgery for esophageal cancer.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80465
Program Number: V042
Presentation Session: Thursday Exhibit Hall Video Presentations Session 2 (Non CME)
Presentation Type: EHVideo
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