Oncological ‘holy Plane’ in Chest for Oesophageal Cancer Resection


Oesophageal carcinoma is an aggressive disease and not all patients are suitable for surgery. In those selected patients who are considered fit for a surgical procedure, the aim is to perform a radical operation to achieve clearance of both the primary tumour and involved lymph nodes. The surgery is technically challenging and we are aware of significant variations between surgeons in terms of their surgical approach.

We perform most of our oesophageal resections with a minimally invasive approach which gives excellent visualisation of the peri-oesophageal tissues. Following careful observation of many such procedures, we believe that the surgery for oesophageal carcinoma can be improved by the identification of tissue planes around the oesophagus, allowing standardisation of surgical approach analogous to the well known total mesorectal excision (TME) of the rectum pioneered by Professor Bill Heald at Basingstoke, England .

We have identified a tissue plane around oesophagus which can be clearly seen with laparoscopic high definition magnification. Identification of this distinct plane requires a careful and methodical approach.The aim of the study was to asses the feasibility of surgical and histological identification of these planes consistently for standardisation.


After seeing this plane clearly during surgery in two cases, the challenge was to identify the visualised layer or structure under the microscope at histological examination.

We successfully identified a layer histologically with special specimen preperation and staining techniques, which we believe correlates to the plane seen at surgery.

After this initial success we have assessed 15 oesophagectomy specimens (retrospective) and five specimens (prospectively) to assess whether this layer is constant in position and identifiable in all cases.


In this joint surgico-pathological presentation we will demonstrate surgical planes and also discuss the preparation of the specimen and histological land marks for identifying the "holy plane" of MIO in our two initial cases where we clearly identified these planes.

We will also discuss the results of our pathological analysis and the potential impact of our findings on oesophageal oncological surgery in the future.

Our study shows that these planes are clearly identifiable in the specimens when the surgeon follows the correct planes during the surgery and the specimens are specially prepared and assessed in the histopathology. However these are less identifiable in ‘routinely’ prepared specimens and if the surgery was done with out taking these planes into consideration.


There are many variations in oesophageal cancer resection surgery. All these approaches offer certain advantage. These surgical treatments can be offered with conventional open or minimal invasive approach. The identification of these planes is possible with both the approaches.

The authors believe that the identification of the plane during oesophagectomy, followed by careful preparation of the resected specimen and microscopic evaluation, will provide us with a method to achieve standardisation in oesophagectomy similar to that well accepted in rectal cancer surgery. The authors hope that the recognition of this “holy plane” may lead to improved circumferential margin clearance in oesophageal cancer surgery, as has been achieved in rectal cancer surgery.

Session: Poster

Program Number: P349

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