Transhiatal Esophagectomy Technique

Updated: Mar 04, 2022
  • Author: Pradeep Saxena, MBBS, MS; Chief Editor: Dale K Mueller, MD  more...
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Technique

Approach Considerations

Transhiatal esophagectomy is performed in five phases, as follows [15] :

  1. Abdominal phase
  2. Cervical phase
  3. Mediastinal dissection
  4. Creation and positioning of the gastric conduit, and abdominal closure
  5. Construction of the cervical esophagogastric anastomosis (CEGA)

Initially, the abdomen is opened and assessed for metastasis and resectability. The stomach is mobilized in preparation for resection. Next, the esophageal hiatus is widened and the mediastinal esophagus is mobilized. In the second and third phases, through a cervical incision, the cervical esophagus is mobilized and upper mediastinal dissection is performed. Finally, the esophagus is resected and a stomach tube created. The stomach tube is brought up in the neck, and esophagogastric anastomosis is done.

The focus of the ensuing technical description is on open transhiatal esophagectomy; however, laparoscopic, [17]  mediastinoscopic, [18, 19] and robotic [20, 21] approaches have also been described (see Minimally Invasive Esophagectomy).

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Transhiatal Approach to Esophageal Resection

Incisions

An upper midline incision is used for abdominal exploration, mobilization of the stomach and transhiatal dissection of the thoracic esophagus. In the neck, an oblique incision is made along the anterior border of the left lower sternocleidomastoid muscle, extending from the left side of the suprasternal notch to the level of thyroid cartilage. Through this incision, the upper esophagus is dissected and freed from the trachea.

Abdominal dissection

The abdomen is explored and carefully examined for the presence of liver metastasis or ascites. The resectability of the tumor is assessed. The stomach or colon that is to be used as a conduit for esophageal replacement is also examined. It should be long enough to reach the neck for a tension-free cervical anastomosis.

A table-mounted self-retaining upper-hand retractor is very useful for exposure and retraction of the left liver lobe. The left triangular ligament is divided with electrocautery, and the left hemiliver is retracted to the right with the blade of the upper-hand retractor.

Gastric mobilization

The lesser sac is entered by serially ligating vessels in the greater omentum about 2-3 cm from the greater curvature of the stomach, with preservation of the right gastroepiploic vessels.

The greater omentum is divided up to the pylorus, with the right gastroepiploic vessels preserved, and the posterior aspect of the stomach is separated from the pancreas.

The greater curvature of the stomach is then freed by serially ligating the left gastroepiploic vessels and the short gastric vessels. These vessels should be ligated well away from the greater curvature of the stomach to prevent ischemia and traumatic injury to the stomach.

The gastrophrenic ligament is similarly divided, and the entire greater curve from the pylorus to the esophagogastric junction (EGJ) is freed. The posterior aspect of the stomach is lifted up and dissected free from the retroperitoneum by dividing a few avascular adhesions.

Incisions and mobilization of the stomach Incisions and mobilization of the stomach

The peritoneum over the lower esophagus is incised, and the EGJ is encircled and separated from the retroperitoneum.

The lesser curvature of the stomach is then similarly freed by entering an avascular part of the gastrohepatic omentum well away from the right gastric vessels. While dividing the gastrohepatic omentum, the surgeon should carefully look for an aberrant left hepatic artery arising from the left gastric artery.

The greater curvature of the stomach is retracted upward and to the right.

The left gastric vein is identified and doubly ligated and divided.

Dissection then proceeds upward toward the high lesser curvature and the esophageal hiatus.

The left gastric artery is identified and ligated at its origin from the celiac trunk, then divided.

All the lymph nodes and soft tissue along the lesser curvature are sequentially dissected and reflected toward the stomach, with as much margin taken as is possible. In this way, the entire lesser curvature and greater curvature of the stomach are mobilized up to the esophageal hiatus.

Mobilization of the stomach Mobilization of the stomach

The peritoneum overlying the diaphragmatic hiatus is incised, and the phrenoesophageal ligaments are divided, so that the lower esophagus is circumferentially separated from the hiatus. If the tumor adheres to the hiatus, a rim of diaphragm at the hiatus may be excised.

Once the stomach is completely mobilized, kocherization of the duodenum and pyloroplasty or pyloromyotomy are performed.

Mediastinal dissection and esophageal mobilization

Liebermann-Meffert documented that the larger arterial blood supply to the esophagus branches into small capillaries approximately 1 cm away from the esophageal wall. Dissection within this immediate paraesophageal space disrupts only these small capillaries, which rapidly spasm; subsequently, thrombosis occurs. Dissection of the esophagus should be carried out in this safe paraesophageal plane. Dissection outside this safe paraesophageal plane may cause injury to the larger vessels, resulting in more blood loss. 

Dissection of the esophagus in this paraesophageal plane is easy in the upper and lower esophagus, where it is done under vision. In the middle portion of the esophagus, however, this dissection is performed blindly and may lead to hemorrhage from tearing of the larger vessels. Also, this blind dissection in the middle esophagus can lead to tearing of the posterior membranous portion of the distal tracheobronchial tree. The surgeon should be vigilant while performing dissection in the midportion of the esophagus, especially in patients with esophageal pathology in this portion of the esophagus or pleural adhesions from infection or prior thoracic interventions in this region.

Thus, the middle region of the esophagus should be thoroughly evaluated via preoperative computed tomography (CT) and endoscopic ultrasonography (EUS). The use of laparoscopic instruments can be very helpful for safe dissection under vision in this region. 

Most of the esophageal dissection is performed under vision from below, through the esophageal hiatus. The hiatus is therefore widened adequately by incising the hiatus anteriorly. This usually requires ligation of the phrenic vein.

Widening of hiatus Widening of hiatus

A Devers retractor is placed in the hiatus to improve exposure. An infant feeding tube is used to encircle the lower end of the esophagus and keep it taut. It also helps to retract the esophagus on either side to facilitate dissection.

A long right-angle clamp is used to entangle adjacent paraesophageal tissue, which is divided with the electrocautery. In this manner, by sequentially dividing small bits of paraesophageal tissue on both sides and by dividing branches of vagal trunk entering the esophagus, the whole of the esophagus can be gradually mobilized and completely freed up to the level of carina. Care is taken to not to breach the pleura during this portion of the dissection. If the pleural cavity is entered, a chest tube should be inserted on that side.

While retraction and dissection is performed near the left atrium, the surgeon should be watchful for hypotension.

Once esophageal mobilization is complete, a pack is placed in the mediastinum through the hiatus, and preparations are made for the cervical part of operation.

Cervical incision and upper mediastinal dissection

An oblique incision is made along the anterior border of the left lower sternocleidomastoid, extending from the left side of the suprasternal notch to the level of the thyroid cartilage.

Cervical Incision Cervical Incision

The platysma is incised in the line of the incision, and the sternocleidomastoid is exposed. The sternocleidomastoid is retracted laterally, and the central tendon of omohyoid muscle is identified. The omohyoid is divided, and, upon incision of the omohyoid fascia, the carotid sheath with its contents is exposed.

The larynx and trachea are retracted medially, and the middle thyroid vein entering the thyroid is identified and divided between ligatures. Similarly, the inferior thyroid artery is identified and divided between ligatures.

With gentle medial retraction of the trachea with fingers and lateral countertraction on the internal jugular vein (IJV), the tracheoesophageal groove, the recurrent laryngeal nerve (RLN), and the cervical esophagus are visualized. (See the image below.)

Exposure of the cervical esophagus Exposure of the cervical esophagus

The prevertebral fascia is then incised, and a finger is insinuated along the esophagus into the superior mediastinum via blunt dissection. The esophagus is freed all around and carefully separated from the trachea.

Both RLNs are identified and excluded from the esophagus, which is then encircled by a finger. An infant feeding tube can then be used to encircle the upper esophagus for retraction and further dissection.

With the esophagus kept taut, blunt finger dissection of the esophagus is further continued. The esophagus is dissected and freed carefully, first posteriorly from the prevertebral fascia and then anteriorly from the trachea. This way, the upper thoracic esophagus is mobilized and freed as much as possible through the cervical incision.

Once again, the thoracic esophagus is visualized through the diaphragmatic hiatus. While traction is maintained on the lower end of esophagus, one hand is inserted through the hiatus and is advanced along the wall of the esophagus. The remaining filmy periesophageal attachments are divided via blunt dissection. The vagal branches are hooked in a right-angle clamp and divided with the electrocautery. This way, complete mobilization of the thoracic esophagus is done (see the images below).

Mobilization of the cervicothoracic esophagus Mobilization of the cervicothoracic esophagus
Esophageal mobilization on anterior aspect Esophageal mobilization on anterior aspect
Esophageal mobilization on posterior aspect Esophageal mobilization on posterior aspect

With traction on the upper infant feeding tube, the mobilized cervicothoracic esophagus is brought out through the cervical wound. The nasogastric tube is pulled out. About 5-7 cm below the cricopharyngeus, a linear cutting stapler is applied anteroposteriorly on the esophagus. The length of cervical esophagus in the neck is always kept a little long; the extra length may be useful if the stomach tube fails to reach the neck.

The esophagus is transected obliquely, with the anterior tip kept a little longer than the posterior tip (see the image below). The stomach and the thoracic esophagus are then pulled and delivered out of the abdominal wound. The mediastinum is inspected for any bleeding or breach of pleura. Hemostasis is achieved, and, if the pleural cavity is breached, a chest tube is placed in the fifth or sixth intercostal space along the anterior axillary line.

Transection of cervical esophagus Transection of cervical esophagus

Esophageal resection and stomach tube creation

After a safe distal margin from the tumor is ensured, the stomach is transected approximately 4-6 cm below the EGJ via successive applications of a linear cutting stapler, TLC 55 (heavy); two or three firings may be required (see the first image below). The resected specimen is then removed from the operating field. The staple line is oversewn with 2-0 silk continuous seromuscular sutures. Thus, a stomach tube approximately 4-6 cm wide is created, with fundus forming its tip (see the second image below).

Creation of stomach tube Creation of stomach tube
Stomach tube Stomach tube

The stomach is then manually manipulated upward through the hiatus and gently pushed up in the neck wound (see the image below). [7] The guiding dictum for stomach mobilization is “pink in the abdomen after complete gastric mobilization and pink in the neck after transposition of stomach through the posterior mediastinum.”

Stomach tube pushed through hiatus toward the neck Stomach tube pushed through hiatus toward the neck

The stomach should be handled with the utmost care. No traction sutures should be applied to pull the stomach up in the neck or to secure the stomach in the neck. Adequate space should be ensured during passage of the stomach tube through the hiatus, mediastinum, and thoracic inlet. Care should be taken to avoid twisting of the stomach tube while it is passed and manipulated up in the neck.

If the length of the gastric tube is insufficient for a tension-free CEGA, the upper sternum may be partially split. Separation of the manubrium only will widen the space and provides exposure of the esophagus in the superior mediastinum. Partial sternal split is also useful in patients with a “bull neck” habitus, obese patients, and elderly patients with cervical osteoarthritis who cannot extend their neck.

A Babcock forceps passed from the cervical wound is used to gently grasp the stomach tube and guide it up in the neck as it is pushed from below. The stomach tube is brought up for about 4-5 cm above the clavicle. At this stage, the tip of the stomach visible in the cervical wound should be pink and healthy, and there should not be any twist on the stomach tube.

Esophagogastric anastomosis and closure of neck wound

Performing an anastomosis about 3-5 cm below the highest point on the anterior wall of the stomach in the neck and creating an acute angle of entry of the esophagus into the stomach leaves some retroesophageal stomach to distend with air and may provide an antireflux mechanism. [7] Use of a side-to-side stapled CEGA has reduced the incidence of anastomotic leakage and subsequent stricture formation. [3, 4]

The stapled suture line of the cervical esophagus is cut and submitted for histology as a proximal margin.

A small 1.5- to 2-cm vertical gastrotomy is made on the anterior wall of the stomach. The gastrotomy should be low enough to allow insertion of a 3-cm-long stapler cartridge for the esophagogastric anastomosis.

The posterior wall of the cervical esophagus is aligned with the anterior wall of the stomach. A stay suture is taken, suturing the superior edge of the vertical gastrotomy to the posterior edge of the transected esophagus.

The anvil of the TLC 55 linear cutting stapler is inserted through the gastrotomy into the stomach approximately 3 cm, and the cartridge of the stapler is inserted into the esophagus. The alignment of the posterior wall of the esophagus and the anterior wall of the stomach is checked again. The anvil and cartridge are engaged. Two interrupted 3-0 sutures are then taken between the anterior wall of the stomach and adjacent esophagus on either side of the stapler. The stapler is then fired to create a 3-cm-long esophagogastric anastomosis. The stapler is then removed, and a nasogastric tube is passed and advanced across the anastomosis into the distal stomach.

The remaining gastrotomy and esophageal defect is closed in two layers. Continuous 3-0 polyglactin full-thickness sutures are used for the inner layer and interrupted 3-0 silk sutures are used for the outer seromuscular layer. The stomach is gently pushed down and the neck wound irrigated with saline.

Esophagogastric anastomosis with a linear cutting Esophagogastric anastomosis with a linear cutting stapler
Completion of the esophagogastric anastomosis Completion of the esophagogastric anastomosis

A 14-French closed suction drain is kept near the anastomosis and brought out from the side. The wound is then closed with interrupted 2-0 polyglactin for the muscle layer and 3-0 silk for the skin.

Abdominal closure

The edge of the diaphragmatic hiatus is sutured to the anterior wall of the stomach via a few interrupted 3-0 silk sutures to prevent herniation of intestines. A feeding jejunostomy is created, and the jejunostomy tube is brought out from the left upper quadrant.

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Postoperative Care

Postoperatively, the patient is kept in intensive care under close monitoring.

Extubation may be done immediately postoperatively, or the patient may be electively ventilated overnight.

Breathing exercises, chest physiotherapy, and regular use of an incentive inspirometer are helpful in early postoperative ambulation.

Jejunal feeds through a feeding jejunostomy are initiated once bowel sounds appear and the patient passes flatus.

A water-soluble contrast study is performed on postoperative day 7; if no leak is detected, oral feeding is resumed. The closed suction drain in the patient’s neck should be left for a sufficient period, usually until postoperative day 10; oral feeding should be delayed if an anastomotic leak is suspected. [8]

The patient is usually discharged in the second postoperative week.

If the histology report indicates positive surgical margins, adjuvant chemoradiotherapy is offered.

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