Ann Thorac Surg 2008;86:989-992. doi:10.1016/j.athoracsur.2008.03.034
© 2008 The Society of Thoracic Surgeons
New Technology
Thoracoscopic Construction of an Intrathoracic Esophagogastric Anastomosis Using a Circular Stapler: Transoral Placement of the Anvil
Ninh T. Nguyen, MD, FACS*,
Marcelo W. Hinojosa, MD,
Brian R. Smith, MD,
James Gray, BS,
Kevin M. Reavis, MD
Department of Surgery, University of California Irvine Medical Center, Orange, California
Accepted for publication March 18, 2008.
* Address correspondence to Dr Nguyen, Department of Surgery, 333 City Blvd West, Suite 850, Orange, CA 92868 (Email: ninhn{at}uci.edu).
| Dr Nguyen discloses a financial relationship with Covidien.
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Abstract
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Purpose: The purpose of this study is to describe a novel technique for thoracoscopic construction of an intrathoracic esophagogastrostomy using a circular stapler.
Description: Conventional method for construction of the esophagogastric anastomosis requires placement of the anvil through an esophageal stump and securing it with a pursestring suture. Advances in stapler technology now permit the anvil to be placed transorally and positioned at the esophageal stump without the need for a pursestring suture.
Evaluation: Ten patients underwent laparoscopic and thoracoscopic esophagectomy with construction of an intrathoracic esophagogastric anastomosis using a circular stapler technique. The anvil was placed transorally in all patients without difficulty. There were no operative complications or postoperative leaks.
Conclusions: The transoral placement of the anvil during thoracoscopic construction of an esophagogastrostomy is technically feasible and may facilitate the performance of the esophagogastric anastomosis using a circular stapler.
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Technology
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Minimally invasive Ivor Lewis esophagogastrectomy is a complex operation. One of the limitations of performing this operation is the technical difficulty of constructing a thoracoscopic, intrathoracic, esophagogastric anastomosis. Many techniques for construction of an intrathoracic esophagogastrostomy have been described. However, the circular stapled technique is the preferred approach [1]. This technique consists of thoracoscopic division of the proximal esophagus at the level of the azygous vein utilizing a linear stapler, placement of a 25-mm anvil transthoracically into the esophageal stump, and closure with a pursestring suture. The circular stapler is then placed transthoracically through a gastrotomy in the gastric conduit in preparation for construction of an esophagogastric anastomosis (Fig 1). When completed, the gastrotomy on the gastric conduit is closed with a linear stapler. A major technical hurdle and time-consuming task during this procedure is placement of the anvil into the esophageal stump. This aspect of the operation requires advanced thoracoscopic suturing and knot-tying skills. Advances in stapler technology now enable surgeons to place the anvil transorally, thereby eliminating the need for thoracoscopic manipulation of the anvil or the need for thoracoscopic suturing and knot-tying.
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Fig 1. Thoracoscopic construction of an intrathoracic esophagogastric anastomosis using a circular stapler, with the 25-mm anvil placed transthoracically through the esophageal stump and secured with a pursestring suture.
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The advance in stapler technology for construction of foregut anastomoses was developed initially within the bariatric surgical literature. Construction of the gastrojejunal anastomosis during laparoscopic Roux-en-Y gastric bypass for the treatment of morbid obesity was first described using a circular stapler. Wittgrove and colleagues [2] reported placement of the anvil transorally. Their technique was similar to that used for percutaneous endoscopic gastrostomy tube placement in which a guidewire is transorally retrieved. The guidewire is then attached to the tip of the anvil, and the anvil is then pulled transorally and positioned within the small gastric pouch [2]. This transoral technique was developed to simplify the process of placing the anvil laparoscopically. Although an ingenious idea, one of the concerns with regard to transoral placement of the anvil has been esophageal or hypopharyngeal injury.
In 2000, Nguyen and Wolfe [3] reported a hypopharyngeal perforation using the transoral technique during construction of a gastrojejunostomy for laparoscopic gastric bypass. The major difficulty with the transoral technique is passage of the round anvil head through the upper esophageal sphincter. Multiple mechanical maneuvers have been used to facilitate the transoral delivery of the anvil, including neck extension, use of an intubation blade to facilitate widening of the oral pharynx, and even deflation of the endotracheal tube balloon. With the technical difficulties of the transoral method, most bariatric surgeons subsequently changed to a laparoscopic technique for placement of the anvil.
In an attempt to improve the transoral technique for placement of the anvil, Gagner and colleagues described (in video format) the technique of transoral placement of the anvil during laparoscopic gastric bypass in which they manually tilted the head of the anvil to facilitate its passage through the hypopharynx and upper esophageal sphincter. The tilted anvil was then manually sutured to the end of an oral-gastric tube in preparation for transoral passage. Once inserted, the oral-gastric tube was laparoscopically withdrawn through a small gastrotomy in the gastric pouch, and the anvil was pulled transorally and positioned within the gastric pouch. The oral-gastric tube was separated from the anvil using the ultrasonic shear. The tilted configuration of the anvil improved the ease of transoral passage, but required manual manipulation and alteration of the device. Recently, a pre-tilted anvil (Orvil [Autosuture, Norwalk, CT]) was developed specifically for the purpose of transoral delivery. In this report, we describe our initial clinical experience using the Orvil for transoral placement of the anvil in preparation for construction of a circular stapled esophagogastrostomy during combined laparoscopic/thoracoscopic Ivor Lewis esophagogastrectomy. This retrospective chart review was approved by the Institutional Review Board of the University of California, Irvine Medical Center.
Surgical Technique
The laparoscopic/thoracoscopic Ivor Lewis esophagogastrectomy technique has been previously described in detail [1]. In short, the operation is performed in two stages. The first stage consists of laparoscopic gastric mobilization with construction of a gastric conduit. The second stage consists of thoracoscopic esophageal mobilization with resection, gastric pull-up, and construction of an intrathoracic esophagogastric anastomosis. Unlike the technique for transthoracic placement of the anvil, transoral placement requires the proximal esophagus be divided using a 60-mm linear stapler (Fig 2). In preparation for transoral placement of the anvil, the anesthesiologist is given the Orvil package (Autosuture, Norwalk, CT), which consists of a 25-mm anvil with the head pre-tilted and the tip attached to an oral-gastric tube (Fig 3). The anesthesiologist must first make sure that there are no other tubes within the esophagus (ie, esophageal stethoscope). The oral-gastric tube with the attached anvil is then passed transorally in the typical fashion. Once the tip of the oral-gastric tube is observed within the esophageal stump, a small esophagotomy is performed perpendicular to the staple line of the esophageal stump (Fig 4). The oral-gastric tube is advanced through the esophagotomy and grasped by the surgeon who pulls it out through a thoracic trocar (Fig 5). During the oral passage, it is important for the anesthesiologist to ensure that the anvil does not get caught on the teeth or the endotracheal tube. The oral-gastric tube is then withdrawn until the anvil is positioned within the end of the esophageal stump (Fig 6). The suture attaching the anvil to the oral-gastric tube is then cut and removed. The oral-gastric tube is separated from the anvil and passed off the operative field (Fig 7). The anvil is now ready for connection to the 25-mm circular stapler. The tilted anvil head will automatically return back to the flat position when the spike of the circular stapler is attached to the anvil in preparation for firing.
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Fig 2. Thoracoscopic view showing the transected esophageal stump using a 60-mm linear stapler at the level of the azygous vein.
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Fig 3. The Orvil (Autosuture, Norwalk, CT) is being placed transorally in preparation for construction of an intrathoracic esophagogastric anastomosis using a circular stapler.
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Fig 4. An esophagotomy is performed perpendicular to the esophageal stump staple line in preparation for retrieval of the oral-gastric tube with the attached anvil.
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Fig 5. The oral-gastric tube is advanced through the esophagotomy of the esophageal stump and removed through one of the thoracoscopic ports.
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Clinical Experience
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Thus far, the transoral technique for placement of the 25-mm anvil has been used with 10 patients who underwent combined laparoscopic and thoracoscopic Ivor Lewis esophagogastrectomy. The passage was technically feasible and successful in all 10 patients. After correct positioning of the anvil, the oral-gastric tube was easily separated from the anvil in all cases. Tissue doughnuts were complete in all cases. There were no postoperative leaks.
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Comment
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The technique of minimally invasive esophagectomy has gone through a spectrum of changes, starting with thoracoscopic and laparoscopic esophagectomy with construction of a cervical anastomosis, to more recently the laparoscopic and thoracoscopic Ivor Lewis esophagogastrectomy. When feasible, our current preferred technique of minimally invasive esophagectomy is the Ivor Lewis technique, consisting of laparoscopic gastric mobilization and thoracoscopic esophageal resection, with construction of an intrathoracic esophagogastric anastomosis. Many techniques have been described for construction of the intrathoracic anastomosis, including the hand-sewn technique, linear stapled technique, and circular stapled technique. However, our current preferred approach is the circular stapler technique [1]. The most difficult task with the circular stapled technique is placement of the anvil into the esophageal stump. Advances in stapler technology now enable the anvil to be placed transorally. The transoral anvil (Orvil) was originally developed for laparoscopic Roux-en-Y gastric bypass to simplify the construction of the gastrojejunostomy. We used our experience with transoral placement of the anvil during bariatric surgery and extrapolated it to our thoracoscopic construction of an esophagogastric anastomosis.
For minimally invasive Ivor Lewis esophagectomy, the transoral technique for placement of the anvil is an innovative and convenient approach. The design of the anvil head is now pre-tilted to allow easy passage through the hypopharynx and upper esophageal sphincter. In addition, the tilted anvil head resumes its flat shape once the anvil is connected to the circular stapler. We have used the transoral placement of the anvil during conventional laparoscopic gastric bypass cases as well as during laparoscopic and thoracoscopic Ivor Lewis esophagectomy. In our experience, transoral placement of the anvil simplifies the placement into the esophageal stump and reduces operative time. Some technical details regarding the optimal placement of the Orvil placement include: (1) performing intraoperative endoscopy to ensure negative margins prior to stapling of the proximal esophagus, (2) sending the intraoperative frozen section of the proximal margin prior to placement of the anvil, (3) placing the oral-gastric tube with the tip pushing against the esophageal stump staple-line prior to making the esophagotomy, (4) making an esophagotomy directly on the staple line against the oral-gastric tube, and finally (5) removing the oral-gastric tube with a towel to prevent contamination of the sterile field. It is also important not to pull excessively on the oral-gastric tube when there is significant resistance, as the anvil is probably lodged at the level of the hypopharynx. In this scenario, the oral-gastric tube that was retrieved from the esophageal stump can be pushed upward until the anvil re-emerges through the mouth. Once the anvil is visible, another attempt for delivery of the anvil can be performed.
In summary, the transoral placement of the pre-tilted anvil head is technically feasible and safe for passage through the oropharynx and esophagus. This new device may facilitate surgeons who are performing a completely intrathoracic esophagogastric anastomosis.
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Disclosures and Freedom of Investigation
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The investigator did not receive any funding to evaluate this new technology. The tested technology was purchased. The authors had full control of the design of the study, methods used, outcome measurements, analysis of data, and production of the written report.
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Footnotes
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Disclaimer The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.
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References
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- Nguyen NT, Longoria M, Chang K, Lee J, Wilson SE. Thoracolaparoscopic modification of the Ivor Lewis esophagogastrectomy J Gastrointest Surg 2006;10:450-454.[Medline]
- Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases Obes Surg 1994;4:353-357.[Medline]
- Nguyen NT, Wolfe BM. Hypopharyngeal perforation during laparoscopic Roux-en-Y gastric bypass Obes Surg 2000;10:64-67.[Medline]
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Abstract
Introduction
