COMPREHENSIVE ATLAS OF SURGICAL TECHNIQUES
The indication for the esophagectomy followed by a coloplasty is restricted to cases of previously operated stomach (as Billroth II distal resection, Nissen fundoplication, gastrostomy) or exceptional peroperative injury of the right gastroepiploic arcade.
Double approach, left cervical and xiphopubic laparotomy.
The Superior Mesenteric Artery (1) and its branches: Middle Colic Artery (2), Right Colic Artery (3), inconstant, Ileocolic Artery (4), Appendicular Artery (5), Anterior Caecal Artery (6), Posterior Caecal Artery (7), Artery for the right angle (8). The Inferior Mesenteric Artery (10) and its branches: Left Colic Artery (11), Colosigmoid Artery (12), Last Sigmoid Artery (Arteria Sigmoida Ima) (13), Sigmoidorectal Artery (14), twin Superior Rectal Arteries (15). The Colic Arcade (9). The Intermesenteric Arcade (18). Arteries originating from Internal Iliac Arteries: Middle Rectal Artery (16), twin Inferior Rectal arteries.
The gastric stump is freed from the transverse mesocolon and omentum and from posterior postoperative adhesions. The efferent limb is dissected.
The efferent limb is stapled and separated from the gastric stump.
After complete gastric mobilization, the D2 node dissection can be carried out around the small gastric curvature and along the common hepatic artery.
A: Right colic mobilization.
B: Left colic mobilization. These mobilization are extensive as the ascending and descending colons must be reconnected as an end step of the operation.
The descending and sigmoid are mobilized as the first portion of the sigmoid will be transposed to the neck.
The transposed colon will receive its vascular supply from the colic arcade issued from the Middle Colic, Right Colic and Ileocolic arteries. The supply from the Left Colic Artery is temporarily interrupted with atraumatic bulldog clamp.
The decending colon and sigmoid are stapled and the ability for the sigmoid to reach the neck is verified.
The esophageal hiatus is enlarged to one hand width.
The cervical esophagus is approached by retracting laterally the sterno-cleido- mastoid muscle and jugular vein. The recurrent nerve follows the tracheo-esophageal groove and is carefully retracted by the of the assistant. The left thyroid lobe is anteriorly retracted.
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 a 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.
The dissection is performed by the cervical finger between esophague and trachea as far as possible.
The bimanual dissection is completed by the abdominal and cervical hands.
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.
The esophagus is delivered in the abdominal cavity.
The descending reverted colon is placed into a wet plastic sheath which and pushed through the hiatus meanwhile the cervical hand pulls the strong threat crossing the posterior mediastinum.
The right colon is delivered at the cervical incision and the esophago-colic anastomosis is carried out in two layers of interrupted slow resorbing 3-0 stitches.
The anastomosis between the descending colon and jejunum is performed in two planes of interrupted 3-0 stitches.
The transverso-sigmoid anastomosis is also carried out in a classical fashion.
It is wise to place a percutaneous jejunostomy.
Closure of the cervical incision leaving a Silastic Penrose drain and of the laparotomy on two Jackson-Pratt drains near the colo-jejunal and colo-colic anastomoses.