Esophageal resection

After checking patient position, skin prepping and sterile draping make a midline skin incision from the xiphoid to the navel, passing the latter on the left. After transecting the subcutaneous tissue with electrocautery open the abdominal cavity along the linea alba.

Insert a circular wound edge protector, thoracic retractor and the Ulrich cable winch retractor.

Explore the entire abdominal cavity to rule out peritoneal and liver metastasis, if necessary, by ultrasonography.

Incise the lesser omentum close to the liver. As shown here, spare any atypical left hepatic artery arising from the left gastric artery. Continue the incision onto the pre-esophageal peritoneum and bluntly open the esophageal hiatus within the tissue layer separating the right crus of diaphragm from the esophagus. Expose the esophagus craniad and to the left crus of diaphragm by blunt dissection. Loop the esophagus with a Penrose drain or like to put traction on it.

After suture ligature of a phrenic vein divide the esophageal hiatus. Dissect the distal esophagus transmediastinally including the lymph nodes between pericardium, mediastinal pleura and aortic wall.

In order to achieve a tension-free gastric transposition, perform a generous Kocher maneuver to free the duodenum. Starting laterad, perform this maneuver until the vena cava and the medial aspect of the aorta are exposed. Now both the duodenum and head of the pancreas are mobile enough that the pylorus can be guided craniad into the esophageal hiatus without difficulty.

Free the greater omentum from the transverse colon and open the lesser sac. Initially leave the greater omentum along the greater curvature. Divide the greater omentum at the gastrolienal ligament near the spleen between Overholt forceps.

Tip:

• During cranial dissection, pack an abdominal towel behind the spleen to prevent any traction on it, which otherwise might tear the spleen. Whenever the situation is ambiguous, be generous with the indication for splenectomy.

Take down the short gastric vessels (vasa brevia) while sparing the spleen. Free the gastric fundus from the retroperitoneum and transect any remaining strands of retrogastric connective tissue.

Best start the suprapancreatic lymphadenectomy (compartment II) at the celiac trunk by exposing the gastroduodenal artery. Follow it up to its junction with the common hepatic artery. Take down all covering lymph nodes and lymph vessels along the common hepatic artery.

Tip:

• Dissection of the hepatoduodenal ligament is simplified by passing the left index finger through the omental foramen (Winslowii).

Continue the lymphadenectomy along the splenic artery into the left upper quadrant. Since there is direct drainage via the retroperitoneum to the hilum of the left kidney, we recommend continuing the dissection up to the renal vein.

When dissecting the common hepatic artery mediad V. gastrica dextra/sinistra  is encountered, which is divided between clips/ligatures.

In the presence of an atypical left hepatic artery arising from the left gastric artery, the latter cannot be suture ligated and divided between Overholt forceps close to its origin, but rather after the left hepatic artery has branched off.

Divide the greater omentum along the greater curvature outside the arterial and venous gastroepiploic arcades. In doing so, the right gastroepiploic artery and vein, which parallel the greater curvature in a fatty envelope from the inferior aspect of the pylorus toward the gastric body, must be preserved at all costs.

When taking down the greater omentum step by step toward the gastric fundus, this is facilitated by grasping the greater omentum and lifting it out of the incision distally. Care must be taken to preserve the rather delicate arcade between the left and right gastroepiploic arteries to prevent any impairment of the blood supply at the tip of the gastric tube constructed later.

The blood supply of the stomach via the right gastroepiploic artery is rather varied but should suffice for the blood supply of the gastric tube to be constructed. It nevertheless is advisable to preserve the right gastric artery arising from the hepatic artery proper in order to ensure adequate blood supply of the gastric tube.

Start constructing the gastric tube along the lesser curvature where the Latarjet nerve (the so-called crow's foot of the vagus nerve) enters the gastric wall.

Divide the stomach by multiple applications of the linear stapler (GIA 60).

Tip:

• Overlap the individual staple lines somewhat to prevent necrosis and gaps.

In terms of postoperative function, it is important to keep the lumen of the gastric tube as small as possible, with a maximum patency of 3-4 cm.