Laparoscopy.com

James D. Luketich, MD, Assistant Professor of Surgery and Director of the Lung Cancer Center with Philip R. Schauer, M.D, Assistant Professor of Surgery and Director of Endoscopic Surgery at The University of Pittsburgh Medical Center, are presenting their operative technique for total thoracoscopic and laparoscopic esophagectomy.

SOURCE: Thoracoscopic and Laparoscopic Esophagectomy. Hiran C Fernando, Neil A. Christie and James D. Luketich. Semin Thorac Cardiovasc Surg. 2000 Jul;12(3):195-200.

Since the laparoscopic fundoplication for gastroesophageal reflux disease was described , there has been a significant improvement regarding surgery of the esophagus. Recently a Pittsburgh group headed by Drs. Schauer and Luketich has developed a technique that safely removes the esophagus by combining a thoracoscopic and laparoscopic approach. Indicated originally in patients with high grade Barrett's dysplasia, this technique can now be used in individuals diagnosed with localized cancer of the esophagus.

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The patient is positioned in the left lateral decubitus (right side up). A 10 mm camera port is placed at the seventh intercostal space at the midaxillary line. A 5 mm port is also inserted at the eighth intercostal space, posterior to the posterior axillary line. Two additional ports are placed for retraction during dissection.

Gastric Bypass enterotomy

This drawing shows the dissection performed inside the thorax. The inferior pulmonary ligament is divided and the mediastinal pleura opened to expose the entire esophagus. The azygus vein is also divided using an Endo GIA stapler. The esophagus with its surrounding fat and lymph nodes is dissected and a Penrose (rubber) drain is placed around it to facilitate exposure. After the esophagus is mobilized, a chest tube is placed through the camera port, all other ports are closed and the patient turned flat.

gastric bypass division of the mesentery

The patient is now placed in the supine position to begin the abdominal stage that involves the mobilization of the stomach and abdominal portion of the esophagus. Ports are placed in a similar fashion as if it were a fundoplication procedure. The stomach is mobilized by dividing the short gastric vessels and the omentum, preserving the right gastroepiploic arcade. The left gastric vessels are divided with an endo GIA stapler and a pyloroplasty is performed.

gastric bypass entero enterotomy

A gastric tube is constructed by dividing the stomach, starting on the lesser curvature (preserving the right gastric artery) using a 4.8 mm stapler.

gastric bypass entero enterostomy closure

The gastric tube is then attached to the esophageal and gastric specimen with two sutures. A laparoscopic jejunostomy is added to the procedure for feeding purposes.

gastric bypass rent closure

The gastric tube is pulled into the mediastinum after the right and left crura are opened.

The final step is a neck incision on the left side. The esophagus is identified and divided. Then the esophagogastric specimen is pulled out of the neck incision and removed from the field. An anastomosis is performed between the esophagus and the tubular stomach.

LAPAROSCOPY.COM would like to thank Dr. Luketich, Director of the Lung Cancer Center, Dr. Philip R. Schauer, M.D, Director of Endoscopic Surgery at the University of Pittsburgh Medical Center and the outstanding work of medical artist Jennifer Dallal for their contribution.