Oesophagectomy by conventional open surgery is the standard of care in the UK today. Most surgeons will perform a resection of the tumour with surrounding lymph nodes in at least two fields (abdomen and chest). Often this is a two stage procedure by laparotomy and right thoracotomy (Ivor Lewis) or a transhiatal resection with a laparotomy and neck incision. With good analgesia and careful perioperative care, operative mortality should be 5% or lower. Having said this, the incisions for open oesophagectomy amount to significant trauma and on average, patients take at least six months to regain their preoperative quality of life.

There are potential advantages therefore in a minimally invasive approach to oesophageal resection. One Unit has lead the field in this procedure, namely the Centre for Minimally Invasive Surgery at the University of Pittsburgh, Pennsylvania under the Direction of James Luketich.

Technical Details


The procedure undertaken in Exeter is based on the UPMC method with minor modifications. Standard staging protocol includes endoscopy, EUS , CT , PET and reCT after chemotherapy if given. Initially we undertook laparoscopic mobilization with right thoracotomy but now routinely use thoracoscopy, laparoscopy and a small (10cm) neck incision. We began with patients with Tis - T2 tumours, but with experience patients with T3 tumours can be resected safely.

Thoracic mobilisation and lymphadenectomy


In the lateral position (R side up), the thoracic oesophagus is mobilized from hiatus to apex of the chest through four 10mm incisions: 7 th ics midax line (retractor), 9 th ics postax line (camera), 9 th ics 2cm posterior to scapular border (right operating) and 7 th ics 2cm posterior to scapular border (left operating). A diaphragm retraction suture is placed into the central tendon and brought out through a small 5mm incision (between retractor and camera incisions in the 9 th ics) to expose the lower third. Dissection is performed along tissue planes, mainly with suction, some diathermy and an ultrasonic scalpel. Oesophageal arteries and thoracic duct are clipped. Great care is taken around the subcarinal space, removing nodes en bloc with the oesophagus avoiding injury to the right and (especially) left main bronchus. The vagus is transected low down to avoid recurrent nerve injury. The azygous vein is divided with EndoGIA 45mm vascular stapler. The oesophagus is dissected above the thoracic inlet, taking care to avoid damage to the trachea. Two Penrose drains are placed around the oesophagus above and below, ready to retrieve from neck and abdomen. Particular diligence in dissection must be made right down to the hiatal fibres, especially medially, which makes the abdominal hiatal dissection easier. A paravertebral catheter is placed under thoracoscopic vision and two intercostal drains placed through the anterior incisions.

Abdominal mobilisation. lymphadenectomy and gastric tube formation


The patient is redraped in the lithotomy position. Ports are placed as shown, using a Nathanson liver retractor to retract the left lobe of the liver and expose the hiatus. The oesophagus is mobilized in the standard manner for a Nissen fundoplication. The remainder of the stomach is mobilized, carefully preserving the gastroepiploic arcade. It is important to free the entire greater curve, right around to the pylorus, avoiding the gastroepiploic artery. Kocher's mobilization is perfomed on the duodenum so that the pylorus will reach the right crus. The left gastric artery is dissected out cleanly onto the coeliac axis removing all nodal tissue down to the origin of the hepatic artery. The left gastric artery and vein is divided with an EndoGIA vascular 45mm cartridge. The lesser omentum is divided with ultrasonic scalpel beyond the first crows foot. The nasogastric tube is removed at this stage. The gastric tube is formed with successive applications of an EndoGIA stapler, taking care to stretch out the stomach towards the spleen with each application. It is important not to shorten the conduit by making the first application of the stapler too obliquely. Care must be taken not to make the gastric tube too narrow (ischaemic necrosis) - a recommended width would be 4-5cm. The lower Penrose drain is now removed per abdomen, after completing the hiatal dissection. The right crus is divided to prevent compromise to the graft. The gastric tube is sutured to the remnant lesser curve ready for transposition into the chest. We do not perform a gastric drainage procedure.

Cervical anastomosis



Towards the end of the abdominal dissection, the second surgeon makes an 8-10cm incision along the anterior border of sternomastoid, deepening through platysma. Omohyoid and the inferior thyroid vein, if present, is divided. After retracting the internal jugular vein and carotid sheath laterally and the thyroid/trachea medially with the finger, the cervical oesophagus is identified and the upper Penrose drain retrieved. Care is taken to avoid injury to the recurrent laryngeal nerve. The specimen is removed from the neck incision under laparoscopic guidance. A neck anastomosis is performed by placing two approximating sutures to the back wall of the anastomosis. An EndoGIA 45 (blue) cartridge is used to create a V-shaped posterior wall (30mm) and the remainder of the anastomosis is performed using interrupted inverting 2/0 Vicryl. The gastric conduit is gently drawn into the abdomen and the hiatus loosely secured around the conduit.

A 9 Fr nasojejunal feeding tube is placed at endoscopy and a nasogastric tube left in the mid conduit.

Patients are kept nil orally until contrast swallow on Day 5, thereafter diet is introduced in a graded manner. Discharge between Day 8 and 10.