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Ann Thorac Surg 2001;72:593-596
© 2001 The Society of Thoracic Surgeons

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Case report

Minimally invasive Ivor Lewis esophagectomy

^a Department of Surgery, University of California, Davis Medical Center, Sacramento, California, USA

Accepted for publication August 2, 2000.

Address reprint requests to Dr Nguyen, Department of Surgery, University of California, Davis, Medical Center, 2221 Stockton Blvd, 3rd Floor, Sacramento, CA 95817-1418
e-mail: ninh.nguyen{at}ucdmc.ucdavis.edu

	Abstract

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Ivor Lewis esophagectomy consists of a laparotomy and right thoracotomy for resection of the intrathoracic esophagus. Recent advances in minimally invasive surgical technology have allowed surgeons to apply laparoscopy and thoracoscopy to perform esophagectomy. However, there have been few reports that describe a totally minimally invasive Ivor Lewis esophagectomy. We present a case of combined laparoscopic and thoracoscopic resection of the distal third esophagus with an intrathoracic esophagogastric reconstruction for esophageal carcinoma.

	Introduction

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Esophagectomy for esophageal carcinoma has been traditionally performed using either the transthoracic (Ivor Lewis) or the blunt transhiatal approach [1, 2]. The type of resection is often based on the location of the tumor and the surgeon’s experience and preference. Recent developments in minimally invasive surgical technology have allowed some surgeons to perform esophagectomy using laparoscopy and thoracoscopy or thoracoscopy alone [3–7]. DePaula and colleagues and Swanstrom and Hansen described the laparoscopic transhiatal esophagectomy technique with a cervical anastomosis [3, 4]. Luketich and colleagues described the combined thoracoscopic and laparoscopic approach with a cervical anastomosis [5, 6]. Watson and coworkers recently described two cases of esophagectomy performed by hand-assisted laparoscopy with a thoracoscopic intrathoracic anastomosis [7].

Our current approach to esophagectomy for intrathoracic esophageal cancer is a combined thoracoscopic and laparoscopic technique with cervical anastomosis [6]. The combined thoracoscopic and laparoscopic approach consists of (1) thoracoscopic esophageal mobilization, (2) laparoscopic gastric mobilization and creation of the gastric conduit, and (3) transhiatal gastric pull-up and cervical anastomosis. We describe here a totally minimally invasive Ivor Lewis resection of the distal third esophageal cancer with involvement of the proximal gastric cardia. A sizable resection of the gastric cardia was necessary to maintain a negative distal margin of resection; therefore, we performed an intrathoracic anastomosis reconstruction.

A 34-year-old man presented with a 2-month history of dysphagia and a 10-lb weight loss. Upper endoscopic examination identified a fungating mass at the gastroesophageal junction. The mass circumferentially involved the gastroesophageal junction and extended to involve the proximal gastric cardia. Biopsy of the mass showed a moderately differentiated adenocarcinoma.

Computed tomography of chest and abdomen demonstrated the gastroesophageal junction mass without evidence of lung or liver metastasis. Endoscopic ultrasound showed a T3N0 lesion. Laparoscopic staging with intraoperative liver ultrasonography was performed that showed no evidence of peritoneal, liver surface, or liver parenchymal metastasis.

The procedure was started laparoscopically with the patient in the supine position. Abdominal insufflation was obtained using a Veress needle. Five abdominal trocars (two 12-mm and three 5-mm) were introduced (see Fig 1 for four of those trocar sites). The left lobe of the liver was retracted upward to expose the esophageal hiatus using a 5-mm liver retractor (Genzyme Corporation, Tucker, GA). The dissection began with mobilization of the greater curvature of the stomach and the gastric fundus. All surgical dissection was performed using the Harmonic Scalpel (Ethicon Endosurgery, Cincinnati, OH) to provide hemostasis. The right gastroepiploic and right gastric vessels were preserved as the blood supplies for the gastric conduit. The gastrohepatic ligament was divided to expose the left gastric vessels. A lymph node dissection was performed at the celiac and gastric vessel confluence. The left gastric vessels were divided with the endoscopic stapler (ENDO GIA II, United States Surgical Corporation, Norwalk, CT) at its junction with the celiac vessels. A Kocher maneuver was performed to further mobilize the stomach in preparation for the transthoracic pull-up. A laparoscopic pyloroplasty was performed by dividing the pyloric muscle longitudinally and closed transversely with a single layer of interrupted suture using an intracorporeal suturing device (ENDO STITCH, US Surgical Corp).

View larger version (107K): [in this window] [in a new window]   Fig 1. Abdominal incisions for minimally invasive Ivor Lewis esophagectomy for placement of three 5-mm (solid arrows) and two 12-mm trocars (open arrows). (Only 4 trocar sites, however, are shown in the figure.)

The patient was then repositioned in a left lateral decubitus position with double lumen endotracheal intubation. Four thoracic trocars (two 10-mm and two 5-mm) were introduced (Fig 2). The mediastinal pleura overlying the esophagus was divided up to the level of the azygos vein. A Penrose drain was placed around the esophagus for retraction and the intrathoracic esophagus was circumferentially mobilized. The entire esophageal specimen and the newly created gastric conduit were delivered through the esophageal hiatus into the right chest. The esophagus was divided with the endoscopic stapler 2 cm below the azygos vein. The esophageal specimen was detached from the gastric conduit and placed into a 15-cm bag. The posterior 12-mm port site was enlarged to a 4-cm incision (Fig 2, large black arrow). The intercostal muscle was divided without resecting a portion of the rib; the specimen was removed through this site.

View larger version (109K): [in this window] [in a new window]   Fig 2. Thoracoscopic incisions for minimally invasive Ivor Lewis esophagectomy for placement of two 5-mm trocars (small arrows), one 10-mm trocar (open arrow), and a 4-cm incision for removal of the surgical specimen (large solid arrow).

The operative time was 2.5 hours for the laparoscopic procedure and 5 hours for the thoracoscopic portion of the procedure. The estimated blood loss was 200 mL. No intraoperative or postoperative blood transfusion was required. The patient was extubated in the operating room and transferred to the intensive care unit. Patient-controlled analgesia with morphine infusion was used for pain control. The patient began ambulation on postoperative day 2 and was transferred to the surgical floor. By postoperative day 4 the patient experienced minimal postoperative pain. Enteral tube feeding was started. A gastrograffin contrast study was performed on postoperative day 6 and demonstrated no leak. There were no postoperative complications and the patient was discharged home on postoperative day 8. Pathology showed a moderately differentiated adenocarcinoma penetrating through the muscularis propria with 11 lymph nodes negative for metastasis. The patient resumed normal daily activity at 2 weeks following the operation. At 4 months the patient continues to tolerate a regular diet and has a functional status similar to that of his preoperative condition. The patient is currently without any evidence of recurrent disease.

	Comment

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Ivor Lewis esophagectomy consists of a laparotomy and right thoracotomy for resection of the esophagus with an intrathoracic esophagogastric reconstruction [2]. Advantages of this technique are the ability to perform a complete mediastinal lymphadenectomy and a good exposure of the mediastinal esophagus to obtain surgical hemostasis. In addition, a wide resection of the gastric cardia is possible, because the anastomosis is performed in the right chest. Disadvantages of the Ivor Lewis approach are the need for single lung ventilation, morbidity associated with a thoracotomy, and the potential for a life-threatening condition if a postoperative anastomotic leak occurs.

Our minimally invasive Ivor Lewis esophagectomy is similar to the operation originally described by Lewis [2] but, instead of a laparotomy and a right thoracotomy incision, we used laparoscopy and thoracoscopy. In the first stage, we commenced with laparoscopy and mobilization of the gastric conduit. The second stage consisted of thoracoscopic mobilization of the esophagus, removal of the esophagogastric specimen, and creation of an intrathoracic anastomosis. Important technical points to emphasize are (1) divide the stomach 2 cm to 3 cm below the gastroesophageal mass to ensure a negative margin of resection, (2) perform a Kocher maneuver to gain length of the gastric conduit, and (3) remove the surgical specimen using a specimen bag to avoid contact of the tumor with the surgical wound. By avoiding a laparotomy and thoracotomy, the patient can benefit from a decrease in postoperative pain, shortened hospital stay, and earlier return to daily activities.

We still advocate the combined thoracoscopic and laparoscopic esophagectomy approach for patients with intrathoracic esophageal carcinoma. However, in selected cases, the minimally invasive Ivor Lewis esophagectomy represents a feasible alternative to conventional thoracotomy and laparotomy. The indications for minimally invasive Ivor Lewis esophagectomy are (1) distal esophageal cancer with tumor extension into the gastric cardia and (2) patients with a shortened gastric conduit as a result of earlier gastric surgery. The current limitation of this technique is the difficulty in creating the intrathoracic esophagogastric anastomosis. Further experience in this anastomosis technique is needed to determine the best method of thoracoscopic reconstruction (stapled or hand-sewn).

	References

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1. Orringer M.B., Marshall B., Stirling M.C. Transhiatal esophagectomy for benign and malignant disease. J Thorac Cardiovasc Surg 1993;106:265-277.
2. Lewis I. The surgical treatment of carcinoma of the esophagus with special reference to a new operation for growths of the middle third. Br J Surg 1946;34:18-31.
3. DePaula A.L., Hashiba K., Ferreira E.A., de Paula R.A., Grecco E. Laparoscopic transhiatal esophagectomy with esophagogastroplasty. Surg Laparosc Endosc 1995;5:1-5.[Medline]
4. Swanstrom L., Hansen P. Laparoscopic total esophagectomy. Arch Surg 1997;132:943-947.[Abstract/Free Full Text]
5. Luketich J.D., Nguyen N.T., Weigel T., Ferson P., Keenan R., Schauer P.R. Minimally invasive approach to esophagectomy. J Soc Laparoendosc Surg 1998;2:243-247.
6. Nguyen N.T., Schauer P.R., Luketich J.D. Combined laparoscopic and thoracoscopic approach to esophagectomy. J Am Coll Surg 1999;188:328-332.[Medline]
7. Watson D.I., Davies N., Jamieson G.G. Totally endoscopic Ivor Lewis esophagectomy. Surg Endosc 1999;13:293-297.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): David M. Follette Peter F. Roberts Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nguyen, N. T. Articles by Goodnight, J. E. Search for Related Content PubMed PubMed Citation Articles by Nguyen, N. T. Articles by Goodnight, J. E., Jr Related Collections Esophagus - cancer