Thoracoscopic Esophagectomy in Dorsolateral Position : An Innovative Approach – the Pawar Technique

Aims: To assess the feasibility of Thoracoscopic Esophagectomy in the Dorso-Lateral position with the intention of reducing the disadvantages and increasing the benefits of lateral approach and prone approach which are the two conventional approaches.

Methods : Thoracoscopic Esophagectomy is routinely performed in two positions. The left lateral decubitus position is the most commonly used position at most of the centres. However prone jack-knife position as described by Cushieri is another alternative.
To combine the advantages and reduce the disadvantages of the two above mentioned positions we started performing this procedure in a Dorso-Lateral position since 1st October 2008 . This is a position midway between the Lateral and Prone position i.e. Left lateral position with an inclination making an angle of 45 degrees with the horizontal. Operating Surgeon and assistant are positioned anteriorly facing the ventral aspect of the patient. A three-port approach is taken with port placements in the 5th, 7th and 9th intercostals spaces in the posterior, mid and anterior axillary lines. Pneumothorax is created with CO2 pressure of 5 – 7 mm Hg. Although single lung ventilation is preferable the procedure can be done with routine dual lung ventilation with a 4th port being used to retract the lung if necessary.
Esophagus is mobilized en-block with posterior mediastinal lymphadenectomy. The Azygous vein and right Bronchial artery are preferably preserved to maintain vascularity of right bronchus.
Following this patient is turned supine and Stomach mobilization and coeliac dissection is done laparoscopically. Left neck incision is taken and esophagus is divided in the neck. Specimen is delivered in the abdomen and extra-corporeally through a mini-laparotomy. Gastric tube is prepared and brought in the neck through posterior mediastinum underneath the azygous vein and rt.bronchial artery for anastamosis in the neck.

Results: In our experience of 24 cases, it was technically easier to do posterior mediastinal , especially the infra-azygous dissection in the dorso-lateral approach as compared to the lateral approach. Also bilateral recurrent laryngeal nerve lymph node dissection were carried out with technically the same ease as in lateral approach.
The position kept the lung and blood away from the posterior mediastinum .
One patient (4.16%) was converted to open procedure due to pulmonary adhesions. Duration of the thoracoscopic dissection was a mean 160 min (100 – 250min) and thoracic blood loss was 100ml (50 – 300ml). Lymph nodes dissected were a median 19 (14-32). Anastamotic leak was seen in 2 patients (8.3%) both minor , which settled with conservative management. There was no mortality and the overall pulmonary complication rate was 21%.

The video shows the procedure in the Dorso-Lateral Position as we routinely perform at our centre.

Conclusion: Thoracoscopic Esophagectomy with Mediastinal Lymphadenectomy in the Dorso-Lateral position is a feasible , more convenient and a safe option which can combine the benefits of the conventional left lateral and prone approaches. Surgeon comfort is enhanced in terms of more comfortable operating position and improved ergonomics.

Session: Podium Video Presentation

Program Number: V009

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