INTRODUCTION:

Throughout the last century, a number of oesophagectomy techniques have been popularized, including Transhiatal, Ivor Lewis, McKeown (or 3-hole), Sweet (or thoracoabdominal) and Minimally Invasive oesophagectomy (MIE) techniques. Significant controversy persists regarding which open approach is best. The MIE has been developed over the last two decades, but its definition remains vague (i.e. hybrid, hand-assisted, laparoscopic, thoracoscopic, and robotic tech-niques), making comparison with open approaches difficult. Factors to consider when deciding between these operative strategies include surgeon experience, tumor location, pulmo-nary reserve, history of previous operations, indication (malignant or benign pathology), and availability of conduit for reconstruction.

Sweet or Left Thoracoabdominal Oesophagectomy

 The Sweet technique utilizes a left thoracoabdominal incision and neck incision for creation of a cervical anastomosis, as the aortic arch prevents creation of a high intrathoracic anastomo-sis. The patient is positioned in a modified right lateral decubi-tus position with the abdomen and hips tilted slightly posteriorly. Left lung is isolation is required. The incision extends from just below the scapular tip, along the 6th or 7th intercostal space, across the costal margin, and then obliquely onto the upper abdomen in a paramedian fashion. The abdominal portion of the incision is made first and once resectability is confirmed, the thoracotomy is made and the incisions are connected by sharply dividing the costal margin. The diaphragm is incised circumferentially for 8–10 cm, leaving a 2 cm cuff for closure. This excellent exposure allows for completion of both the abdominal and chest stages through a single incision. After resection, the conduit is passed beneath the aortic arch and the cervical stage with a cervical anastomosis is com-pleted. The diaphragm is closed and the costal margin is reapproximated with figure-of-eight sutures. The thoracoabdominal incision is then closed in layers after drains are placed.

 The Sweet esophagectomy is ideal for locally advanced distal esophageal tumors, such as tumors invading the dia-phragmatic hiatus, as this wide exposure provides optimal access to the hiatus and gastroesophageal junction. The main disadvantages of this technique include increased postoperative pain owing to the large incision, as well as risk of costal arch dehiscence and diaphragm dysfunction.

IVOR LEWIS OESOPHAGECTOMY

The ILE consists of an upper midline laparotomy followed by repositioning and right thoracotomy for resection and recon-struction with an intrathoracic anastomosis. With the patient supine, the abdominal stage is performed first. After ruling out metastatic disease, the stomach is mobilized, the left gastric is pedicle divided and celiac lymphadenectomy are performed, the gastric conduit is created, and adjunct procedures (i.e. pyloroplasty and J-tube) completed. The tip of the conduit is attached to the specimen for later retrieval in the chest. The abdomen is closed and the patient is repositioned in the left lateral decubitus position. Single-lung ventilation is initiated (a double-lumen endotracheal tube or bronchial blocker is required to isolate the right lung). Following right thoracotomy, the intrathoracic esophagus is mobilized and mediastinal lymphadenectomy is performed. The conduit is then pulled up into the chest, the esophagus is transected proximal to the disease, and the specimen is removed. The intrathoracic esophagogastric anastomosis is then performed. After the chest has been washed out, drains/chest tubes are placed and the chest is closed.

 ILE is an ideal operative strategy for mid-esophageal and distal esophageal tumors, as this approach allows excellent visualization for complete mobilization of the esophagus and lymphadenectomy. The number of lymph nodes harvested tends to be greater with a thoracic approach and the risk of vocal cord paralysis is lower by avoiding the neck dissection needed for a cervical anastomosis. Anastomotic leaks are less common, presumably due to less tension on the intrathoracic anastomosis in comparison to a cervical anastomosis where the conduit must be pulled up for a greater distance. Historically, intratho-racic anastomotic leaks tended to result in greater morbidity due to associated mediastinal sepsis or empyema. However, appropriately placed drains and percutaneous drainage tech-niques have resulted in less morbidity from intrathoracic leaks in the current era. Pulmonary complications and more postop-erative pain are the primary negatives of the ILE, attributed mainly to the thoracotomy. 

McKeown (Three-Hole) Esophagectomy

 Three incisions are required for the McKeown technique: a right thoracotomy, an upper midline laparotomy, and a left neck incision. The right chest is entered first to carry out mobilization of the intrathoracic esophagus and mediastinal lymphadenectomy. Once the esophagus has been mobilized, the chest is closed without dividing the esophagus. The patient is then placed in the supine position and the remainder of the procedure is carried out in similar fashion to the THE. However, blunt mediastinal dissection is not required, as the intratho-racic esophagus has already been completely mobilized.

 The McKeown esophagectomy has both the advantages and disadvantages of the ILE and THE. An additional incision increases the chance of wound complications and increased postoperative pain. A unique advantage to this technique is that pathology at any level can be addressed.

Minimally Invasive Esophagectomy (MIE)

 The MIE is technically challenging and requires significant minimally invasive surgical expertise. The learning curve is steep with an estimated 35–40 MIE’s needed for a surgeon to become proficient from a technical and patient-care standpoint. Although open esophagectomy techniques continue to be favored by the majority of surgeons today, the number of centers performing MIE continues to increase. A totally minimally invasive esophagectomy is per-formed with only laparoscopy and thoracoscopy, avoiding rib spreading, rib resection, or hand-assistance and is the authors’ favored technique when technically feasible. Hybrid procedures are those in which either the abdominal phase or the thoracic phase is performed open. Alternatively, a hand- assisted port may be added to facilitate the operation. The steps of the procedure are identical to that of the ILE if the anastomosis is to be placed in the chest. If a cervical anastomosis is needed, a neck incision is added and the steps are carried out in similar fashion to the McKeown or transhiatal esophagectomy techniques. Port size and loca-tion is variable by surgeon. Five to six ports are typically used for the abdominal stage and 4–5 ports are used for the chest stage. A diaphragm retraction stitch placed in the tendinous portion of the diaphragm can be used to improve visualization of the distal esophagus during the thoracoscopic approach (Fig. 16.21). The specimen is removed through the neck wound for a McKeown or tran-shiatal MIE, while one of the chest port sites is extended to 4-cm and the specimen is removed without rib spreading for an Ivor Lewis MIE. Proper port placement is critical, mak-ing sure ports are spaced sufficiently enough apart to avoid crossing of instruments and poor angles. The majority of images provided in this chapter were obtained from laparoscopic-thoracoscopic MIE’s, demonstrating the excellent visualization provided during these operations. A high-definition camera with an angled 30- or 45° scope typically provides the best views.

   Advantages and disadvantages are similar to the corresponding open technique used for MIE. Additional advantages of the minimally-invasive approach include less postoperative pain, fewer pulmonary complications, less intraoperative blood loss, and shorter lengths of stay. Although there is no absolute contraindication to MIE, relative contraindications include a history of multiple prior thoracic or abdominal sur-geries, bulky T3 or T4 tumors, preoperative radiation therapy, and morbid obesity. Resectable T4 tumors invading surround-ing structures are likely best approached in an open fashion. It is recommended that surgeons earlier on in their learning curve select early stage esophageal tumors, such as Barrett’s esophagus with HGD, T1 (invading the lamina propria or sub-mucosa), or T2 (invading muscularis propria) lesions without previous neoadjuvant therapy.     

Transhiatal Esophagectomy (THE)

 THE consists of an upper midline laparotomy combined with a left neck incision for creation of a cervical anastomosis. The patient is placed in the supine position and both the neck and abdomen are prepped into the field. Only a single-lumen endotracheal tube is needed. The abdominal stage is carried out in similar fashion to the ILE, however much of the intra-thoracic esophageal mobilization is performed by blunt dis-section. As much of the esophageal mobilization as possible is performed under direct vision from the abdomen and neck to divide aortoesophageal branches and other attachments. The remaining mobilization is performed blindly with the surgeon’s left hand inserted through the neck incision and the right hand through the abdominal incision. Blunt dissection is performed to free up any remaining attachments until the dissection planes from above and below are met. Bleeding is not uncommon during the blunt dissection, as aortoesopha-geal branches are blindly avulsed. However, most bleeding is stopped by packing the mediastinum. Once the esophagus is completely mobilized, it is divided in the neck proximally and the specimen is removed through the abdominal wound. The conduit is then brought up into the neck to create the cervical anastomosis. One technique used to bring the conduit up into the neck is to pass a Penrose drain or chest tube from the neck to the abdomen. The tip of the conduit is attached to the tube or drain and the conduit is then gently pushed/pulled up through the mediastinum and delivered into the neck. The cervical esophagogastric anastomosis is then performed.

 THE is a useful technique for benign disease that does not require a lymphadenectomy, but may also be used for malignant lesions located in the middle and lower esopha-gus. However, THE may be contraindicated for bulky tumors in the middle esophagus that may be adherent to mediastinal structures. Avoiding a thoracotomy has resulted in fewer pulmonary complications and less postoperative pain, which makes the THE an ideal approach for those with significant pulmonary disease. Operative time tends to be shorter, as there is no need to reposition the patient during the course of the procedure. Cervical anastomotic leaks tend to be associated with less morbidity, as simple opening of the wound is all that is needed in most cases and contamination of the mediastinum or pleural space is uncommon. Downsides of THE include harvesting of fewer lymph nodes, greater blood loss, and higher incidence of injury to intrathoracic structures due to the blunt mediasti-nal dissection. Although cervical anastomotic leaks tend to be easier to manage in the peri-operative period and are associated with less morbidity, they occur more frequently and also develop strictures at a higher rate. The higher leak and stricture rate of cervical anastomoses are presumably from increased tension placed on the anas-tomosis. The neck dissection also increases the risk of recur-rent laryngeal nerve injury, which is commonly associated with postoperative aspiration.