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The left thoracoabdominal incision provides excellent exposure for operations dealing with the distal esophagus or proximal stomach. It is particularly useful for complex reoperations in this region, which are typically quite difficult due to the presence of significant adhesions involving the stomach, diaphragm, and liver. The left thoracoabdominal incision is indicated for (1) resection of carcinomas of the lower third of the esophagus or esophagogastric junction; (2) resection of middle third esophageal carcinomas, where the tumor is located below the carina; and (3) complex esophageal repairs, notably reoperative antireflux surgery. In complex reoperations at the esophageal hiatus or in primary repairs of massive hiatal hernias, a left thoracotomy incision alone with division of the periphery of the diaphragm may be sufficient. However, the left thoracoabdominal incision is a useful extension of this approach to facilitate superior exposure and safer conduct of the surgery.
The left thoracoabdominal incision can also be combined with a left neck incision to perform total esophagectomy with cervical esophagogastrostomy. With slightly caudal extension of the lower end of the incision, the left colon may be mobilized for use as a replacement conduit for the esophagus using this approach. Finally, the left thoracoabdominal incision provides superb exposure for performance of total gastrectomy. The incision easily facilitates Roux-en-Y reconstruction to the distal esophagus.
The left thoracoabdominal incision is not an ideal approach when access is needed to the esophagus at or above the carina because the arch of the aorta obscures access to the esophagus at this level. Relative contraindications to this incision include a prior left thoracotomy, and prior right pneumonectomy because left lung deflation is necessary to achieve satisfactory exposure.
It is essential to conduct an appropriate work-up of the patient preoperatively. In the case of esophageal resection for cancer, the barium swallow and endoscopy are critically important to determine the upper limit of the esophageal access necessary. Computerized tomography is also useful for this assessment and for evaluating the extension of tumor to surrounding mediastinal structures. Preoperative assessment for complex operations or reoperations for benign esophageal disease should include a careful history, barium swallow, endoscopy, and esophageal manometry, possibly combined with extended pH monitoring.
Anesthetic treatment of patients undergoing left thoracolaparotomy includes the preoperative placement of a thoracic epidural catheter. This is important for postoperative pain relief and can be retained for up to 5 days. Other routine aspects of monitoring include insertion of a radial arterial line in the right arm and Foley catheter. Either a left-sided double lumen tube, or standard endotracheal tube with left bronchial blocker may be used to deflate the left lung during the operation. Of note, if the left thoracolaparotomy is to be combined with a left neck incision for total esophagectomy, the left arm will need to be free draped. In this scenario, no intravenous or arterialt lines should be placed in the left arm.
The immediate postoperative care depends on the magnitude and length of the operation. In the case of a fairly straightforward operation, immediate extubation can be accomplished. Otherwise, the author prefers to ventilate electively the patient overnight with a plan for extubation the following morning. The thoracic epidural catheter is critical for the achievement of sufficient pain relief, to permit vigorous coughing, and clearing of secretions.
The chest tube is maintained on −20 cm water continuous suction. Ongoing management of the chest tube depends on the nature of the operation. In the event of esophagogastrectomy, the chest tube typically has been sutured near the esophagogastric anastomosis. The author prefers not to remove this tube until the patient has had at least 48 hours of oral intake postoperatively. This conservative approach is performed to permit satisfactory external drainage in the event of an anastomotic leak. Occasionally, small leaks are not appreciated on the initial contrast esophagogram but instead become manifest after initiating oral intake within the ensuing couple of days. Outside this scenario, the chest tube may be removed when there is no evidence of air leak and when the fluid drainage is less than 200 mL per 24 hours.
The history of the left thoracoabdominal incision, its technical evolution, and its many clinical applications have been previously discussed by Heitmiller.
This approach accommodated the creation of an endothoracic esophagogastric anastomosis below the aortic arch; supra-aortic esophageal anastomosis was also possible but required making a second chest entry at the fourth intercostal space.
Increasing experience with esophageal resection for carcinoma has led most surgeons to perform subtotal esophagectomy with cervical esophagogastric anastomosis. The advantages of subtotal esophagectomy for cancer include a higher likelihood of a tumor-free esophageal margin, a better functional result regarding the ease of swallowing and less tendency to gastroesophageal reflux, a lower risk of septic complications with an anastomotic leak, and the placement of the anastomosis remote from mediastinal lymph node stations when postoperative adjuvant radiotherapy is necessary. Matthews and Steel popularized the combination of left thoracolaparotomy incision combined with left neck incision for subtotal esophagectomy with cervical anastomosis.
The left thoracoabdominal incision provides superb exposure for esophagogastrectomy, allows en bloc dissection, and permits the very precise placement of the gastric conduit. The conduit can be carefully checked simultaneously in the chest and abdomen, and can be sutured to the pleura and peritoneum to minimize the chance of torsion or tension. Another practical advantage of this approach for esophageal resection is the single positioning and sterile field necessary to accomplish the entire operative procedure. The advantage of excellent simultaneous exposure in the abdomen and chest is also extremely useful during reoperative antireflux surgery,
and in total gastrectomy, where a Roux-en-Y jejunal limb originates within the abdomen but passes through the esophageal hiatus for anastomosis with the distal esophagus in the lower mediastinum.
A notable drawback of the thoracoabdominal incision is postoperative pain. The consequences of severe, incisional pain include lower lobe atelectasis and, less frequently, pneumonia. The liberal use of thoracic epidural catheters, along with retention of these catheters for up to 5 days postoperatively, has made the control of early perioperative pain in these patients much more straightforward. Other problems resulting from this incision relate to the division of the diaphragm. The potential impairment of postoperative diaphragmatic function can be minimized by keeping the phrenotomy confined to the periphery, staying within approximately one inch of the chest wall attachment. Another potential complication is delayed herniation of abdominal viscera through the site of prior diaphragm division. Once again, paying careful attention to technical detail during the closure of the diaphragm, as previously mentioned, minimizes the potential for this problem. Finally, a troublesome chrondritis at the site of division of the costal arch will develop in a small minority of patients. However, this is especially problematic if associated with suppuration, in which case reoperation for débridement and excision of infected cartilage becomes mandatory.
For these reasons, the author confines the use of the left thoracoabdominal incision to those selected cases in which simultaneous, extensive exposure is necessary within the chest and abdomen. It is the author's incision of choice for total gastrectomy. It is also the most reliable approach for reoperative antireflux surgery when thoracotomy and phrenotomy are insufficient, and for complex reoperations aimed at restoring esophageal-gastric continuity after catastrophic complications from prior surgery in this region.