Laparoscopic and Thoracoscopic Ivor Lewis Esophagectomy

Minimally invasive (MIS) Ivor-Lewis Esophagectomy is a technically challenging procedure, but series from expert centers have described its feasibility and safety. The benefit in terms of long-term oncologic outcomes is being investigated. The extent of MIS techniques has ranged from a laparoscopic abdominal component with a thoracotomy, mini-thoracotomy, or thoracoscopic component. This video describes the main steps of a MIS laparoscopic and thoracoscopic Ivor Lewis esophagectomy with upper abdominal and subcarinal lymph nodal dissection and the circular stapled anastomosis with the transoral anvil. We have performed MIS Ivor Lewis Esophagectomy in thirty-seven patients (mean age 67 years; range 45 to 85) with distal esophageal adenocarcinoma (n=29), squamous cell cancer (n=5), or high-grade dysplasia in Barrett’s Esophagus (n=3) between October 2007 and August 2009. The abdominal portion of the operation was completed laparoscopically in 30 patients (81.1%). The thoracic portion was completed using a mini-thoracotomy in 23 patients (62.2%) and thoracoscopic techniques in 14 (37.8%). Proximal and distal margins were negative in all patients. A median of 15 lymph nodes (range 8 to 33) were dissected from each specimen, with a median of 3 (range 0 to 18) histologically positive nodes. No intra-operative technical failures of the anastomosis or deaths occurred. The average hospital stay was 11 days (range 7 to 30). Five patients had strictures (13.5%) and all were successfully treated with either two or three endoscopic dilations. One patient had an anastomotic leak that was successfully treated by re-operation and endoscopic stenting. The operation shown includes laparoscopic hiatal, distal esophageal, and gastroesophageal junction dissection and lymph nodal dissection of the porta-hepatis, left gastric artery, and supra-pancreatic lymph stations. Gastric conduit preparation was performed using multiple firings of a 4.8mm linear stapler. A pyloroplasty was performed and a feeding jejunostomy placed. The thoracic portion was completed using standard thoracoscopic ports and techniques and included mobilization of the esophagus from the esophageal bed, subcarinal lymph node dissection and transection of the most superior aspect of the thoracic esophagus at the level of the thoracic inlet with a 4.8mm linear stapler above the divided azygous vein. The esophagogastric anastomosis was performed using a 25mm anvil passed trans-orally, in a tilted position, and connected to a 90cm long PVC delivery tube through a small opening in the stapled esophageal stump. The anastomosis was completed by joining the anvil to a circular stapler (EEA 25mm with 4.8mm Staples) inserted into the gastric conduit. Then, the gastric conduit opening was closed using an additional firing of a 4.8mm linear stapler.
While long-term oncologic outcomes are still being evaluated, MIS Ivor Lewis Esophagectomy is feasibe and seems safe in high volume centers. It also seems to offer superior visualization of the operative fieldin addition tothe usual benefits of MIS techniques.

Session: Podium Video Presentation

Program Number: V043