Esophagectomy

After sterile washing and covering as well as checking the positioning, a skin incision is made along the midline from the xiphoid to the umbilicus with left circumincision of the umbilicus. Opening of the abdominal cavity in the linea alba after transecting the subcutaneous tissue with the electrocautery.
Insertion of an inner covering foil and a Mercedes retractor as well as an Ulm retractor.
Exploration of the entire abdominal cavity to rule out peritoneal carcinomatosis and liver metastasis, if necessary by sonography.

Incision near the liver of the lesser omentum. An atypical left hepatic artery originating from the left gastric artery, as present here, must be preserved. The incision is extended to the pre-esophageal peritoneum, the esophageal hiatus is bluntly opened in the cleavage plane between the right diaphragmatic crus and the esophagus. Blunt preparation of the esophagus cranially and to the left diaphragmatic crus. Slinging of the esophagus with a rubber band.

After ligation of a diaphragmatic vein, division of the esophageal hiatus. Transmediastinal preparation of the distal esophagus with dissection of the lymph nodes between the pericardium, mediastinal pleura and anterior wall of the aorta.

To achieve a tension-free gastric interposition, an extensive Kocher duodenal mobilization is performed. This is done from the lateral side so far that the V. cava and the medial edge of the aorta are exposed. Subsequently, the duodenum and pancreatic head are so mobile that the pylorus can be guided upwards into the esophageal hiatus without difficulty.

Dissection of the greater omentum from the transverse colon and opening of the omental bursa. In this process, the greater omentum is initially left at the greater curvature. The greater omentum is detached close to the spleen in the area of the gastrosplenic ligament using Overholt clamps.

Tip: The spleen should be padded with an abdominal swab during the cranial dissection to prevent traction that can lead to tearing of the spleen; if necessary, a generous splenectomy must be performed.