Abdominothoracic esophageal resection according to Ivor Lewis with intrathoracic anastomosis. Standardized totally minimally invasive technique

Background. The clinical and scientific interest in minimally invasive techniques for esophagectomy (MIE) are increasing; however, the intrathoracic esophagogastric anastomosis remains a surgical challenge and lacks standardization. Surgeons either transpose the anastomosis to the cervical region or perform hybrid thoracotomy for stapler access. Aim. This article reports technical details and early experiences with a completely laparoscopic-thoracoscopic approach for Ivor Lewis esophagectomy without additional thoracotomy. Material and methods. The extent of radical dissection follows clinical guidelines. Laparoscopy is performed with the patient in a beach chair position and thoracoscopy in a left lateral decubitus position using single lung ventilation. The anvil of the circular stapler is placed transorally into the esophageal stump. The specimen and gastric conduit are exteriorized through a subcostal rectus muscle split incision. The stapler body is placed into the gastric conduit and both are advanced through the abdominal mini-incision transhiatally into the right thoracic cavity, where the anastomosis is constructed. Data were collected prospectively and analyzed retrospectively. Results. A total of 23 non-selected consecutive patients (mean age 69 years, range 4680 years) with adenocarcinoma (n=19) or squamous cell carcinoma (n=4) were surgically treated between June 2010 and July 2013. Neoadjuvant therapy was performed in 15 patients resulting in 10 partial and 4 complete remissions. There were no technical complications and no conversions. Mean operative time was 305 min (range 220-441 min). The median lymph node count was 16 (range 4-42). An R0 resection was achieved in 91% of patients and 3 anastomotic leaks occurred which were successfully managed endoscopically. There were no postoperative deaths. Conclusion. The intrathoracic esophagogastric anastomosis during minimally invasive Ivor Lewis esophagectomy can be constructed in a standardized fashion without an additional thoracotomy. Reduction of surgical morbidity remains the highest priority.