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.