Technique of Open Ivor Lewis Esophagectomy

(A, B) The Ivor-Lewis esophagectomy is performed through an upper midline laparotomy and then a thoracotomy (A) and typically includes a two-field lymphadenectomy (B) encompassing periesophageal, subcarinal, superior mediastinal, diaphragmatic, paracardial, lesser curvature, and celiac axis lymph nodes (levels 2, 3, 4, 7, 8, 9, 15, 16, 17, and 20). The operation begins with an esophagoscopy to confirm the extent of tumor. On opening the abdomen, the right gastroepiploic artery is palpated and its fitness as the blood supply for the gastric conduit is confirmed. Abdominal exploration should confirm absence of liver metastases, extensive nodal disease, omental metastases, etc. v. = vein.

(A-C) The left triangular ligament is divided and the left lobe of the liver is retracted (A). The gastrohepatic ligament is incised as close to the liver as possible. One should always look for a replaced left hepatic artery, especially if a vessel appears unusually large. Further dissection may be needed before ligating such a vessel (see legend to Fig. 5). The phreno-esophageal ligament is incised and the esophagus is circumferentially dissected (B, C). The hiatus is widened by incising the crura. If the tumor is bulky, a cuff of diaphragm can be included with the specimen. lig. = ligament.

(A-C) The left triangular ligament is divided and the left lobe of the liver is retracted (A). The gastrohepatic ligament is incised as close to the liver as possible. One should always look for a replaced left hepatic artery, especially if a vessel appears unusually large. Further dissection may be needed before ligating such a vessel (see legend to Fig. 5). The phreno-esophageal ligament is incised and the esophagus is circumferentially dissected (B, C). The hiatus is widened by incising the crura. If the tumor is bulky, a cuff of diaphragm can be included with the specimen. lig. = ligament.

The esophagus is encircled with a large penrose drain. The lower esophagus can be mobilized under direct vision transhiatally to confirm resectability of the tumor. The hiatus is enlarged to fit four fingers of a size 7 gloved hand.

Before mobilizing the greater curvature of the stomach, two laparotomy pads are placed behind the spleen to lift the spleen forward. The lesser omental sac is entered at least 2 cm beyond the right gastroepiploic artery (usually at the midpoint of the stomach where the omentum is most transparent). Using the Harmonic Wave (Ethicon Endo-Surgery, Inc., Guaynabo, Puerto Rico), the dissection is carried to the level of the pylorus and proximally to the first short gastric vessel. Care must be taken to avoid any injury to the right gastroepiploic artery, and one must be particularly vigilant in obese patients as the omentum thickens and the left transverse colon encroaches on the stomach as the “bare area” is approached. The short gastric vessels are either individually ligated or secured with the harmonic scalpel. The author prefers to work from the most proximal short gastric distally to the bare area. The vascular reflection of the peritoneum at the esophagogastric junction is incised (meeting the penrose drain). At times short vessels from the splenic artery run to the back of the cardia and must be ligated. The entire greater curvature should now be mobilized. Hemostasis is assured in the splenic bed and the laparotomy pads behind the spleen are removed. a. = artery.

The stomach is now held up out of the incision and cephalad to expose the celiac axis. Small vessels and lymphatics superior to the pancreas are carefully clipped as dissection of the areolar tissue proceeds. It is important to avoid injury to the pancreas as well as the splenic artery, which is often very tortuous. The left gastric (coronary) vein is identified and ligated. The left gastric artery coursing directly superiorly to the stomach is identified and dissected. All lymph nodal tissue at the celiac trifurcation is swept upward to be included en bloc with the specimen. The left gastric artery can be tied and suture ligated proximally or frequently easily secured with an endovascular stapler. Before securing the left gastric artery, the surgeon should look for an accessory hepatic artery or left hepatic artery arising from the left gastric. Such a finding necessitates ligation closer to the stomach. a. = artery.

The lesser curvature of the stomach is mobilized from the hiatus to the right gastric artery. The entire gastrohepatic ligament is included with the specimen to resect lesser curvature lymph nodes. Posterior dissection continues along and often includes part of the left crus to the hiatus. A generous Kocher maneuver is then performed. IVC = inferior vena cava; lig. = ligament.

A pyloric drainage procedure is now performed. Choices include pyloromyotomy, pyloroplasty, and more recently botox injection. Some perform no drainage procedure. Pyloromyotomy was the author's preferred procedure, but recent experience with botox injection has been satisfactory. Two hundred units of botox is mixed in 5 mL of normal saline and approximately 1.25 mL is injected into the pyloric muscle at the one o'clock, 3 o'clock, 6 o'clock, and 9 o'clock positions. To aid in the resection of the proximal stomach when drawn into the right chest, the gastrohepatic tissue at the point of resection of the distal lesser curvature is cleared. This point is about six vascular arcades distal to the esophagogastric junction. The celiac axis is marked with a long stitch to aid pathologic examination. A jejunostomy tube is then placed 30 to 40 cm beyond the ligament of Treitz. The abdomen is closed.

The patient is placed in the left lateral decubitus position, prepped, and draped. A right posterolateral thoracotomy incision is made, and the fifth intercostal space is entered. The lung is deflated using the double lumen endobronchial tube placed at the beginning of anesthesia. The azygos vein is divided using the endo GIA 30, 2.5 stapler (Endo GI Universal, US Surgical, Norwalk, CT). The pleura is scored with the electrocautery from posterior to the azygos down to the hiatus. The inferior ligament is incised and the pleura scored back to the cut azygos vein. Boundaries of dissection are now marked. The esophagus is then dissected and encircled with a large penrose drain at the level of the arching azygos vein. Care must be taken with this maneuver to avoid entering the esophageal muscularis propria as the posterior muscle fibers are often “splayed” deep into the mediastinum. v. = vein.

Using the penrose as a traction device, the esophagus and the attached lymphoareolar tissue are mobilized from the mediastinal bed. Aortic branches are clipped. The dissection includes mobilization of the subcarinal lymph node packet, which is kept intact with the specimen and marked with a double stitch. The pericardium is “bared.” The vagal nerve trunks are cut as the esophagus is mobilized from the lower superior mediastinum. Once the hiatus is reached, final attachments are released. Level 15 (diaphragmatic) lymph nodes are carefully identified and resected. The thoracic duct is purposely ligated at this level by mass ligature of all tissue between the aorta, spine, and azygos vein using a 0-silk tie.

The nasogastric tube that was placed after the endoscopy is withdrawn to the thoracic inlet. The esophagus is stapled above the azygos vein using a GI stapler with a “green load” (such as PI 30 mm stapler; US Surgical).

With care to preserve proper orientation, the stomach is delivered through the hiatus into the chest. The gastric conduit is formed by several applications of the ILA 100-mm stapler (US Surgical) or use of the 60-mm endostapler (Endo GIA Universal, US Surgical). The previously cleared portion of the distal lesser curvature serves as a distal marker. The highest point of the fundus is easily identified when the stomach is put on “stretch.” If the tumor is at the gastroesophageal junction, a more “V-shaped” staple line will increase the radial gastric margin. The highest point of the staple line is oversewn with a 3-0 silk horizontal mattress suture as well as where staple lines have crossed each other. GE jct = gastroesophageal junction.

While awaiting for the results of the frozen section examination of the esophageal plus/minus gastric margins, a superior mediastinal lymph node dissection is done, and levels 2 and 4 lymph nodes sent for permanent pathologic examination. Once the margins are clear, the anastomotic setup is commenced. The esophagus is circumferentially dissected proximally 3.5 to 4 cm from the staple line. The esophagus is then laid on the surface of the stomach, which has been placed in the previous esophageal bed. The esophagus is secured by four 3-0 silk sutures as illustrated. A small V-shaped esophagotomy is made in the midpoint of the staple line. A 3-0 silk suture is placed through the upper “lip” of the esophagotomy, including both muscle and mucosa, and is tagged. A small gastrotomy is made with the electrocautery. Another 3-0 silk suture is placed catching the posterior “lip” of the esophagotomy and posterior margin of the gastrotomy. These sutures are guiding sutures for the arms of the endostapler used for the anastomosis.

The endostapler [author uses the 35-mm endoscopic articulating linear cutter (Ethicon Endo-Surgery, Cincinnati, OH) with the blue load] is opened and the larger arm is inserted into the esophagus. The other arm is inserted into the stomach via the gastrotomy. The guiding sutures are gently tugged downward to assure full insertion of both arms of the stapler. The stapler is closed, fired, and released. The stapler forms a side-to-side functional end-to-end anastomosis. The nasogastric tube is passed into the distal stomach. The esophagotomy and gastrotomy are closed with interrupted full-thickness sutures of 3-0 silk. To help avoid delayed emptying, excess conduit is placed back into the abdomen, and the conduit is gently “tugged” to make it as straight as possible. Tacking sutures are not used. The right pleural cavity is irrigated with normal saline; chest tubes are placed (posterior straight chest tube and right-angle tube over the diaphragm), and the thoracotomy is closed in standard fashion.