Ann Thorac Surg 1997;63:255-257
© 1997 The Society of Thoracic Surgeons
How To Do It
Patient Position for a Synchronous Cervicothoracoabdominal Two-Team Esophagectomy
Sandro Mattioli, MD,
Franco D'Ovidio, MD,
Massimo P. Di Simone, MD,
Andrea Lazzari, MD,
Rolando Paladini, MD,
Bruno Begliomini, MD
Department of Surgery, Intensive Care, and Organ Transplantation, University of Bologna, Bologna, Italy
Accepted for publication August 2, 1996.
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Abstract
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Cervicothoracoabdominal and cervicoabdominal approach are routinely adopted for total or subtotal esophagectomy. We propose a modification of the Nanson's patient position to optimize sequential or simultaneous left cervicotomy, laparotomy, and eventual right thoracotomy with one or two surgical teams. This technique permits better control of the operative field for each phase of the procedure with coordinated operating of two surgical teams on the neck, abdomen, and chest.
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Introduction
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In 1975 Nanson [1] reported a synchronous combined approach for the abdominothoracocervical esophagectomy. He described a position to be taken by the patient that permitted access to the three surgical sites without the need to reposition the patient. Limitations to this position have been described: difficult illumination when operating in the chest, difficult visualization and exposure of the lower third of the esophagus, and difficult access to the posterior mediastinum and esophageal bed at the level of the aortic arch and main carina [2]. Other positions described with the goal of eliminating the need to reposition the patient also reveal nonoptimal exposure of each surgical field [3–5]. We report a modification of Nanson's position that permits optimal access to the three surgical fields as if each one were approached singularly. The advantages of no repositioning, no redraping, and a combined two-team job are preserved.
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Technique
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The main feature of this technique is the possibility, by rotating the table on each side, of obtaining a horizontal supine patient position or a right chest up patient position as for a normal laparotomic or thoracotomic procedure.
The patient is positioned on the bed with a 30-degree tilt of the body on the left side (Fig 1A
). The legs are positioned as for a right thoracotomic procedure. The right hand and forearm are gloved with a soft padding and the hand is tucked under the right loin (Fig 2). All fingers must be well extended (Fig 3). The trunk is kept in position by a right buttock ovalor rubber padded support and by a square swiveling rubber padded body support placed at the level of the right scapula (see Fig 2). The right elbow is rested on a square swiveling rubber padded arm support to avoid tension on the right shoulder joint and on the brachial plexus (see Fig 2). On the left side the body is framed by a long tubular rubber padded body support placed along the chest and abdomen (Fig 4). Recently the multiple positioning-induced pressure points have been protected by using viscoelastic polymer products.
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Fig 1. . (A) Patient in the 30-degree left side tilted position. (B) Horizontal supine position after the 25-degree right rotation of the table. (C) Right chest up position after the 25-degree left rotation of the table.
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Once completed, the position is tested by rotating the operating table on each side (Figs 1B, 1C
). We use a surgical table that permits a 25-degree rotation on each side and maintains stability when the patient is in the horizontal supine position in which the entire body weight is completely off center with respect to the base of the bed (Fig 1B). Complete distant anesthesiologic monitoring must be provided before draping because during the operation there is limited access to the patient.
Abdominal exposure, after a xipho-umbilical laparotomy, is obtained either by using two upper hand retractor blades anchored to a bar with a parallelipid section, which is sustained parallel to the body by a custom bent rod locked, on the right side, to the rails of the table (Fig 5A), or by using a Kent retractor system (Fig 5B). Either of these systems is functional when the bed is in the right-rotated position to get the patient into the horizontal supine position.
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Fig 5. . Retractor systems that permit optimal abdominal exposure with the patient in the horizontal supine position and the bed in a right 25-degree rotation. (A) Upper-hand retractor blades anchored to a parallelepipid bar sustained by a bent rod locked on the right side to the rails of the bed. (B) Kent retractor system.
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A two-team operation may be carried out with one team working on the abdomen and one on the neck. Each team is composed of a first surgeon, an assistant surgeon, and an operating room nurse. The thoracotomic phase of the dissection, when needed, is performed by rotating the bed to the left until the right chest up position is obtained (see Fig 1C). During this phase only one team is operating. Before the thoracotomy is started, the bed is split just below the scapula. The thoracotomy is performed through an anterolateral incision. The chest is entered through the fourth or fifth intercostal space, depending on the somatic features of the patient and on the target. To gain more exposure, the intercostal muscles are freed posteriorly from the upper border of the rib on the inferior side of the thoracotomy almost to the spine. Care is taken not to injur the sympathetic chain. Closure of the three surgical sites may be carried out simultaneously by partial left rotation of the table starting from the horizontal supine patient position.
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Comment
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Our variation of the Nanson's position permits the operation to be carried out as if each step of the procedure were performed singularly and yet without redraping or repositioning of the patient. It maintains the advantage of shortening the operating time by means of a synchronous combined two-team operation. As opposed to the simultaneous thoracoabdominal approach described by Nanson, we suggest one team working on the neck and one on the abdomen, followed by simultaneous closure of the three surgical sites. During the thoracotomy phase, the field is adequately exposed and illuminated thanks to the site of the breakage of the bed. The posterior extension from inside of the thoracotomy and the fact that the patient is in a right chest up position, which moderately shifts the heart to the controlateral side, in association with moderate left-lung positive end-expiratory pressure, permit excellent exposure of the posterior mediastinum and easy dissection of the entire thoracic portion of the esophagus not possible with the Nanson position [2], and easy standard or extended thoracic lymphadenectomy [6]. Tumors located in the thoracic outlet are easily approached with optimal exposure of both the thoracic inlet and outlet. Sequential and combined transcervical and thoracotomic dissection is optimized by giving different rotations to the table.
On the other hand, in contrast to what has been reported by authors using a stationary body tilted position [1, 3, 4], the horizontal supine position of the patient allows, through a midline laparotomy, best exploration of the intrabdominal organs, excellent control of the short gastric vessels while performing the gastric mobilization, and best view of the posterior mediastinum while performing the transhiatal dissection. Moreover, the assistant's work is more comfortable and educational.
In our case series morbidity due to the patient position occurred postoperatively in an overall 6% of cases (5/83). The postoperative complications were a transient right arm peripheral neuropathy in 2 patients, paresthesia of the right hand in 1, edema of the right arm in 1, and a finger blister in 1. These complications were absolutely minor, none had permanent effects, and all occurred after procedures that lasted more than 8 hours. Recently we have adopted viscoelastic polymer products made of Akton (Action Products, Inc, Hagerstown, MD) to protect the position-induced pressure points. Right arm free draping [7] may avoid the above complications, but has the disadvantage of free positioning the arm with the risk of inadvertently allowing extreme arm postures while operating.
Disadvantages of the proposed positioning are the extra set-up time (20 to 30 minutes total) and extra equipment (body, arm, and buttock supports, available accessories for most surgical tables); therefore, we believe it to be best if esophageal operations are routinely performed.
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Acknowledgments
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We thank Nadia Nuvoli for the excellent illustrations.
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Footnotes
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Address reprint requests to Dr Mattioli, Dipartimento di Discipline Chirurgiche, Rianimatorie e dei Trapianti, Sezione Chirurgia Generale, Università di Bologna, Via Massarenti, 9, 40138 Bologna, Italy.
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References
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- Nanson EM. Synchronous combined abdomino-thoraco-cervical esophagectomy. Aust N Z J Surg 1975;45:340–8.[Medline]
- Pearson FG. Synchronous combined abdominothoracocervical esophagectomy. In: Pearson FG, Deslauriers J, Hiebert CA, McKneally MF, Ginsberg RJ, Urschel HC Jr, eds. Esophageal surgery. New York: Churchill Livingstone, 1995:677–82.
- Chung SCS, Griffin SM, Wood SDS, Crofts TJ, Li AKC. Two team synchronous esophagectomy. Surg Gynecol Obstet 1990;170:68–9.[Medline]
- Gurtner GC, Robertson CS, Chung SCS, Li AKC. Two team oesophagectomy. Br J Surg 1994;81:1620–2.[Medline]
- Ginsberg RJ. Left thoracoabdominal cervical approach. In. Pearson FG, Deslauriers J, Hiebert CA, McKneally MF, Ginsberg RJ, Urschel HC Jr, eds. Esophageal surgery. New York: Churchill Livingstone, 1995:665–8.
- Bumm R, Wong J. Extent of lymphadenectomy in esophagectomy for squamous cell esophageal carcinoma: how much is necessary? Dis Esoph 1994;7:145–221.
- De Graaf PW, Idenburg FJ, Obertop H. A uniform approach for esophagectomy with or without thoracotomy. Surg Gynecol Obstet 1991;173:149–52.[Medline]
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Abstract
Introduction
