A New Operative Approach for GEJ Adenocarcinoma
The video provides a step-by-step approach to laparoscopic esophagogastrectomy.
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The important concepts of each major step of this operation are highlighted.
Patient positioning and abdominal access. The patient is placed in low-lithotomy position, with all pressure points adequately padded. Preoperative antibiotics and deep venous thrombosis prophylaxis are administered. Access to the peritoneal cavity is obtained with a Veress needle in the left upper quadrant at Palmer's point. Four additional trocars are placed, and a Nathanson liver retractor is inserted in the epigastrium (Figure 5).
Figure 5. Laparoscopic esophagogastrectomy is performed with the patient in low-lithotomy position, with five laparoscopic ports and a Nathanson liver retractor.
Mobilization of the greater curve of the stomach. The lesser sac is accessed at the mid-point along the greater curvature of the stomach, leaving the gastroepiploic vessels with the stomach. It is imperative that the gastroepiploic vessels remain intact and with the stomach, because these will provide blood supply to the gastric conduit.
Esophagogastric lymphadenectomy. Throughout the dissection of the distal esophagus and proximal stomach, attention should be paid to ensure that all associated lymphatic tissue remains with the specimen. The lymphatics of the left gastric vessels should be dissected away from the vessel prior to transection with a vascular staple load. In the posterior mediastinum, the borders of the lymphadenectomy basin are the left and right pleura (lateral), the pericardium (anterior), and the aorta (posterior).
Intraoperative endoscopy. Endoscopic evaluation at the time of esophagogastrectomy is used to identify the distal and proximal extents of the tumor. This is essential to ensure that proximal and distal margins are obtained at the time of esophageal and gastric transection.
Creation of an esophagogastric anastomosis. The esophagogastrostomy is created in the distal posterior mediastinum. To ensure appropriate anastomotic length and alignment, stay sutures are placed to anchor the esophagus to the stomach. Once the esophagus and stomach are opened, the esophageal mucosa can easily become pulled away from the muscular wall of the esophagus and compromise the integrity of the anastomosis. To prevent this, an additional full-thickness suture is placed prior to performing the stapled anastomosis, to maintain the esophageal mucosa at the edge of the anastomosis.
The incidence of adenocarcinoma of the GEJ is increasing. In patients with locally advanced tumors, trimodality therapy (chemotherapy, radiotherapy, and operative resection) provides the best chance for long-term survival. In patients with extensive cardiac and pulmonary disease that renders them prohibitively high risk for esophagectomy and gastrectomy, operative resection of the GEJ can be performed with laparoscopic esophagogastrectomy.
Operative Technique
The video provides a step-by-step approach to laparoscopic esophagogastrectomy.
This feature requires the newest version of Flash. You can download it here.
The important concepts of each major step of this operation are highlighted.
Patient positioning and abdominal access. The patient is placed in low-lithotomy position, with all pressure points adequately padded. Preoperative antibiotics and deep venous thrombosis prophylaxis are administered. Access to the peritoneal cavity is obtained with a Veress needle in the left upper quadrant at Palmer's point. Four additional trocars are placed, and a Nathanson liver retractor is inserted in the epigastrium (Figure 5).
Figure 5. Laparoscopic esophagogastrectomy is performed with the patient in low-lithotomy position, with five laparoscopic ports and a Nathanson liver retractor.
Mobilization of the greater curve of the stomach. The lesser sac is accessed at the mid-point along the greater curvature of the stomach, leaving the gastroepiploic vessels with the stomach. It is imperative that the gastroepiploic vessels remain intact and with the stomach, because these will provide blood supply to the gastric conduit.
Esophagogastric lymphadenectomy. Throughout the dissection of the distal esophagus and proximal stomach, attention should be paid to ensure that all associated lymphatic tissue remains with the specimen. The lymphatics of the left gastric vessels should be dissected away from the vessel prior to transection with a vascular staple load. In the posterior mediastinum, the borders of the lymphadenectomy basin are the left and right pleura (lateral), the pericardium (anterior), and the aorta (posterior).
Intraoperative endoscopy. Endoscopic evaluation at the time of esophagogastrectomy is used to identify the distal and proximal extents of the tumor. This is essential to ensure that proximal and distal margins are obtained at the time of esophageal and gastric transection.
Creation of an esophagogastric anastomosis. The esophagogastrostomy is created in the distal posterior mediastinum. To ensure appropriate anastomotic length and alignment, stay sutures are placed to anchor the esophagus to the stomach. Once the esophagus and stomach are opened, the esophageal mucosa can easily become pulled away from the muscular wall of the esophagus and compromise the integrity of the anastomosis. To prevent this, an additional full-thickness suture is placed prior to performing the stapled anastomosis, to maintain the esophageal mucosa at the edge of the anastomosis.
Summary
The incidence of adenocarcinoma of the GEJ is increasing. In patients with locally advanced tumors, trimodality therapy (chemotherapy, radiotherapy, and operative resection) provides the best chance for long-term survival. In patients with extensive cardiac and pulmonary disease that renders them prohibitively high risk for esophagectomy and gastrectomy, operative resection of the GEJ can be performed with laparoscopic esophagogastrectomy.
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