C Palanivelu, MS, FACS, FRCSEd, DSc, R Parthasarathi, P Senthilnathan, MS, FMAS, DNB, S Rajapandian, MS, FRCS, FMAS, P Praveen Raj, MS, FMAS, N Ramesh, MS, M Bharath Cumar, MS, S Saravana Kumar, MS. GEM Hospital & Research Centre
Background: Colon is one of the preferred conduits for esophageal replacement following corrosive esophageal injury. Use of both right and left colon has been described. However, case-reports or videos describing totally minimally invasive approach to this complex surgery are scarce.
Methods: Pre-operative evaluation: A 23 years old female presented with dysphagia for both solids and liquids following acid ingestion 8 months back. She had undergone 3 unsuccessful balloon dilatations and hence referred for surgical management. Barium swallow showed stricture of entire thoracic esophagus from 20cm onwards upto just above Gastro-esophageal junction with normal filling of stomach.
Surgical Details: Surgery was carried out in 3 phases – Abdominal (laparoscopic), Thoracic (thoracoscopic) and then again Abdominal (laparoscopic). Initially, patient was placed in supine position with leg split. Right colon was mobilized medial to lateral by retrocolic tunneling, Ileo-colic vessels were temporarily clamped with bull-dog clamps and adequate blood supply to right colon and terminal ileum was ascertained. Subsequently, ileocolic vessels were divided, terminal ileum was transected and right colon and terminal ileum were mobilized based on middle colic artery. Then, GE junction was mobilized and laparoscopic transhiatal mobilization of lower esophagus was done upto inferior pulmonary vein. Esophagus was transected at GE junction using linear stapler. Right mediastinal pleura was incised and colonic conduit was placed in right thoracic cavity.
Now, patient was placed in semi-prone position and ports were placed in right thorax. Remaining mobilization of thoracic esophagus – upto thoracic inlet – was performed thoracoscopically safeguarding surrounding structures. Dense periesophageal inflammation and fibrosis was encountered. Esophagus was divided at thoracic inlet after ascertaining adequate vascularity and luminal patency of proximal end. End-to-end hand-sewn esophago-ileal anastomosis was performed at thoracic inlet using interrupted 3-0 PDS sutures thoracoscopically.
Patient was again placed in supine position. Transverse colon was transected now, just distal to middle colic vessels, to ensure adequate length of conduit. Hand-sewn end-to-side colo-gastric anastomosis was done on anterior surface of stomach. Side-to-side ileo-transverse anastomosis was done using staplers.
Results: Post-operative period was uneventful. Oral gastrograffin study on 5th POD confirmed integrity of both esophago-ileal and colo-gastric anastomoses. She was discharged on 10th post-operative day on solid diet.
Discussion: A complex procedure – esophagectomy with colonic interposition for corrosive stricture – was performed by total thoracoscopic-laparoscopic approach.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 79482
Program Number: V006
Presentation Session: Foregut 1
Presentation Type: Video