COMPREHENSIVE ATLAS OF SURGICAL TECHNIQUES
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The patient is placed in left lateral decubitus for the posterolateral thoracotomy.
The thoracotomy is performed in the 5th intercostal space. The right lung is retracted anteriorly. The esophagus is located on the anterior aspect the spine and the parietal pleura is opened between the azyos vein and the diaphragm. It must stay attached with the esophagus and will be removed with it as well as the fat and lymphatic tissue around it. At this thoracic level the pneumogastric nerve often presents as a plexual structure. The thoracic duct, posterior to the esophagus is ligated.
The esophagus is dissected free in the cephalic direction. The pneumogastric nerve is clipped. The azygos vein is interrupted and hemostasis of stumps is performed with two running 5-0 Prolene R sutures. The descending aorta is now palpable and visible.
The upper esophagus is dissected from the posterior part of the trachea and the lymphatic tissue surounding it. The right recurrent nerve is seen crossing behind the subclavian artery and the left one is carefully preserved in its aortic contact. Both vagal nerves can be interrupted after the origin of the recurrents. The intertracheobronchial lymph nodes are removed. The upper mediastinum is enlarged to facilitate the later access from the cervical incision and passage of the gastric tube.
The chest is closed leaving a 28-French thoracic drain. The abdominal and cervical incisions are in red. The abdomen is approached with a supraumbilical laparotomy.
The mobilization of the stomach starts at the lower part of the greater omentum. The latter is opened caudally to the gastroepiploic arcade. The epiploic then the gastrosplenic vessels are ligated. At that stage the left crus of the diaphragm can be sectioned.
The right part of the greater omentum is opened unto the pylorus then the smaller omentum. The posterior wall of the stomach is freed from adhesions with the pancreas and the right crus is cut.
The esophageal hiatus is enlarged to 7-10 cm. The pericardium is gently pushed posteriorly and the left pleura laterally.
The Kocher maneuver:
A: The retroperitoneum is cut in front of the right kidney.
B: The duodenopancreatic block is elevated and can be held in the left hand.
C: At the end of the maneuver the duodenum can be retracted on the left thus discovering the IVC and abdominal aorta.
A: The left gastric artery is ligated at its origin from the celiac axis.
B: At this stage the D2 lymphatic dissection can be carried out from the common hepatic artery to the celiac axis. The hepatic and splenic arteries are freed from any lymphatic content on the spine of the pancreas. The posterior limit of the dissection is the nervous celiac plexus.
Pyloroplasty: the pylorus is sectioned longitudinally and sutured transversally with slow resorbing separated stitches.
The cervical incision is performed on the left sternocleidomastoid muscle. The internal jugular vein is retracted laterally and the thyroid gland anteriorly. The esophagus is approached lateral to medial. The left recurrent nerve is dissected along its cervical passage. It must be protected during this step and retracted by the hand of the assistant and not with metallic retractor not to damage it. The esophagus encircled. The right recurrent nerve is not visible. So the dissection must stay as near the right wall of the esophagus as possible.
A: The cervical esophagus is cut. Its distal stump is closed and a strong and long threat is firmly sutured to this extremity.
B: The abdominal hand pulls the abdominal esophagus.
A: The esophagus is delivered in the peritoneal cavity.
B: The smaller curvature is stapled from its angulus with the linear device.
C: The stomach is tubulized along the greater curvature. Finally the esophagus and gastric body adjacent to the smaller curvature are separated.
It is wise to place a percutaneous jejunostomy.
A: The gastric tube is placed in a wet plastic sheath. The strong threat that has followed the esophagus from the cervical to the abdominal incision is firmly attached to the sheath.
B: The left hand of the operator pushes the sheath towards the mediastinum while the right one pulls the strong threat.
The sheath and gastric tube is delivered at the neck incision. Care must be taken to avoid a twisting of the tube when it ascends to the neck. A good trick is to verify that the vascular gastroepiploic bundle in on the left part of the preparation. The sheath is removed from the neck incision.
The vascularity of the tube is verified. A gastrotomy adapted to the esophageal section is performed and the esogastric anastomosis is carried out in two planes of slow resorbing separated stitches.
The abdomen and cervical incision are closed leaving two drains, respectively near the hiatus and gastroesophageal anastomosis.