Radical En Bloc Esophagectomy for Carcinoma of the Esophagus

After successful placement of an epidural catheter for postoperative analgesia, the patient is placed in the left lateral position. A straight right lateral thoracotomy is performed and access to the hemithorax is obtained through the fifth interspace. The sixth rib is not resected; however, a one centimeter segment of rib undercover of the paraspinal fascia is excised to facilitate retraction of the rib cage. Occasionally, tumors at the gastroesophageal junction and tumors within the hiatal tunnel are approached through a left sixth interspace thoracotomy—abdominal access in such cases is achieved through a peripheral semilunar diaphragmatic incision.

(A and B) The basic concept of an en bloc resection is extirpation of the tumor-bearing esophagus within a bloc of surrounding tissues including both pleural surfaces abutting the esophagus laterally, the dorsal lymphovascular tissue wedged between the esophagus and the descending thoracic aorta, including the thoracic duct and a patch of pericardium where the latter abuts the tumor bearing segment of the esophagus.

(A and B) The dissection begins by incising the mediastinal pleura directly overlying the trunk of the azygous vein from the level of the azygous arch superiorly to the aortic hiatus inferiorly. Dissection continues dorsally and to the left until the descending thoracic aorta is encountered mobilizing the thoracic duct anteriorly toward the en bloc specimen. All lymphatic tributaries of the duct are either clipped or ligated.

Once the aorta is encountered, dissection proceeds anterior to the aorta ligating all esophageal and bronchial vessels. Finally, with strong forward retraction, the contralateral pleura is seen and incised from the level of the left main bronchus to the diaphragm. Ligation and division of the thoracic duct inferiorly at the aortic hiatus and superiorly at the azygous arch concludes the posterior dissection.

The anterior dissection begins by division of the azygous arch at its caval junction anteriorly. Further dissection proceeds along the right main bronchus with dissection of the subcarinal space and along the medial border of the left main bronchus. The dissection then proceeds inferiorly where the pericardium is incised just anterior to the tumor bearing segment of the esophagus. Working from within the pericardial cavity, a quadrangular patch of pericardium is excised en-bloc with the tumor bearing segment of the esophagus.

Once the pericardial patch is excised, a plane is developed medial to the left main bronchus and the en bloc specimen is encircled in an umbilical tape or penrose drain. Both vagus nerves are identified and divided at this point. The diagram illustrates the completed dissection of the subcarinal space, the periarotic tissue with the ligated thoracic duct, and the exposed left lung and myocardium.

Dissection of the distal third of the esophagus proceeds by division of the right inferior pulmonary ligament and dissection along the pleuro-pericardial reflection. The specimen is then lifted from within the mediastinum and the contralateral inferior pulmonary ligament is divided, avoiding injury to the left inferior pulmonary vein. With strong traction on the specimen, the cautery is used to resect a circumferential one inch ring of diaphragm around the esophagus at the hiatus.

Superiorly, the esophagus is mobilized by blunt and sharp dissection from the prevetebral tissue and the membranous trachea to the neck. This dissection is carried bluntly and sharply all the way to the prevertebral space in the neck. This maneuver will greatly facilitate retrieval of the mobilized esophagus through the cervical incision. This completes the intrathoracic portion of the procedure. The right hemithorax is drained and closed. The patient is repositioned for the cervical and abdominal portions of the operation.

The abdomen is entered through an upper midline incision. Division of the left triangular ligament and retraction of the left lobe of the liver greatly facilitates exposure of the upper abdomen. The omentum is separated from the mesocolon in the avascular plane and the short gastric vessels are ligated and divided. The lesser sac is entered and the stomach is retracted cephalad. The retroperitoreum is incised along the splenic artery to the celiac access. All lymphatics superior to the pancreas are swept toward the hiatus. The left gastric artery and coronary vein are ligated and transected. The lymph nodes along the common hepatic artery are also resected.

The electrocautery is used to complete division of the diaphragm if necessary, and to divide the gastrohepatic ligament. A Kocher maneuver is usually performed and a pyloromyotomy is always done.

Through a transverse cervical incision the prevetebral space is entered, and the previously mobilized cervical esophagus is easily retrieved and transected.

The en bloc specimen is pulled into the abdominal cavity and transected distally using a stapling device, thus simultaneously creating a greater curvature gastric tube.

The gastric tube is passed across the posterior mediastinum where an end-to-side esophagogastrostomy is performed. After completion of the anastomosis, all redundancy in the gastric tube is reduced into the abdomen and the tube is secured to the edges of the neo-hiatus with sutures to prevent herniation of the bowel into the negative pressure environment in the chest.