Video-Assisted Esophageal Mobilization—Video 23

Published on 13/02/2015 by admin

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CHAPTER 23 Video-Assisted Esophageal Mobilization—Video 23

Robert J. McKenna, Jr.

Introduction

Mobilization of the esophagus by video-assisted thoracic surgery (VATS) offers the advantage of a complete cancer operation performed with minimally invasive surgery. Although most VATS procedures are performed with the patient in the lateral decubitus position, the prone position offers several advantages for surgery on structures in the posterior mediastinum. Because gravity causes the lung to fall out of the way, lung retraction required in the lateral position is not needed when the patient is prone. Only three small incisions are needed to perform the procedure. The planes of dissection are the azygous vein, aorta, pericardium, vertebral bodies, and the trachea, allowing a thorough cancer operation with wide dissection and a complete nodal dissection to be performed.

Approach to Video-Assisted Esophageal Mobilization

Order of Operative Steps

The order of the steps of the operation are as follows: dissect on pericardium, dissect along azygous vein and aorta, remove subcarinal nodes, clip the thoracic duct, transect the azygous vein, and dissect the esophagus at the apex of the chest.

Key Points

♦ Perform esophagogastroduodenoscopy with the patient in the supine position on the gurney, and then place the patient prone on the operating table.
♦ Dissect inferiorly to superiorly in the chest.
♦ Dissect along the pericardium first, because if dissection along the azygous is done first, the esophagus falls in the way when dissecting the pericardial plane after the posterior dissection.

image Video-Assisted Esophageal Mobilization (Video 23)

Step 1. Esophagoscopy and Positioning

♦ With the patient asleep and in the supine position on the gurney, perform esophagogastroduodenoscopy.
♦ Move the patient in the prone position on the operating room table. Place a roll vertically under the sternum to lift the patient off the operating room table so skin preparation can include the entire posterior chest. On the right side, the preparation extends anterior to the anterior axillary line.

Step 2. Incisions

♦ Incision 1: Place a 5-mm trocar in the mid-axillary line in the fifth intercostal space. This is primarily used for the thoracoscope.
♦ Incision 2: Make a 1-cm incision in the seventh intercostal space in the posterior line.
♦ Incision 3: Make a 5-mm incision in the posterior axillary line in the third intercostal space.
♦ Encourage lung decompression with carbon dioxide insufflation.

Step 3. Anterior Esophageal Dissection

♦ Exposure: Gravity makes the lung fall anteriorly, out of the way.
♦ Aim the thoracoscope inferiorly with the lens pointed toward the ligament.
♦ Pass the thoracoscope through incision 3.
♦ Through incision 2, pass the Harmonic scalpel or electrocautery to cut the inferior pulmonary ligament as a grasper pulls the ligament anteriorly and superiorly.
♦ Dissect along the pericardium, the bronchus intermedius, and the left mainstem bronchus. This mobilizes the subcarinal lymph nodes, which are sent as a separate specimen for analysis.
♦ Lift the esophagus with a grasper through incision 1 (Figure 23-1).
image

Figure 23-1 Initial exposure of the esophagus with the patient prone.

Step 4. Posterior Esophageal Dissection

♦ Exposure: Lift the esophagus away from the azygous vein.
♦ Aim the thoracoscope inferiorly with the 30-degree lens pointed posteriorly.
♦ With the Harmonic scalpel through incision 2, mobilize the esophagus from the azygous vein.
♦ The esophagus is then allowed to drop anteriorly, and the aorta can be seen. Continue dissecting along the surface of the aorta. Identify small arterial branches from the aorta to the esophagus, and clip or seal them with the Harmonic scalpel. The midportion of the esophagus is completely mobilized; continue the dissection toward the diaphragm.
♦ Dissect the pleura by the distal esophagus parallel to the diaphragm. Clip the thoracic duct with a large endoscopic clip passed through incision 2 (Figure 23-2).
♦ With an endoscopic clip applier through incision 2, clip all the tissue on the lateral surface of the esophagus parallel to the diaphragm (Figure 23-3).
image

Figure 23-2 Dissection of the anterior surface of the esophagus.

image

Figure 23-3 Thoracic duct for clipping.

Step 5. Dissection of the Proximal Esophagus

♦ Exposure: The lung falls anteriorly.
♦ Aim the thoracoscope posteriorly with the 30-degree lens pointed superiorly.
♦ With the Harmonic scalpel, mobilize the azygous vein as it courses anteriorly toward the superior vena cava. When it is fully mobilized, transect the azygous vein with a stapler from incision 2 (Figure 23-4).
♦ With a grasper through incision 3, elevate the esophagus from the posterior wall of the trachea so the Harmonic scalpel can incise the pleura and the remainder of the anterior aspect of the esophagus (Figure 23-5).
♦ With the grasper, pull the esophagus away from the spine so the Harmonic scalpel can incise the pleura and the rest of the esophagus from the spine. This dissection can be carried into the neck (Figure 23-6).
image

Figure 23-4 Stapler across the azygous vein.

image

Figure 23-5 Clipping the tissue on the lateral surface of the esophagus near the diaphragm.

image

Figure 23-6 The esophagus is mobilized to the neck.

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