Left-Sided Approach to Esophageal Mobilization for Minimally Invasive Esophagectomy in a Patient With a Right-Sided Descending Aorta

In the minimally invasive age, thoracic dissection for esophagectomy is most commonly conducted through the right hemithorax. However, anatomical variation requires a tailored, patient-specific approach. In this case, a left-sided approach for esophageal mobilization in a minimally invasive esophagectomy was safe and effective in a patient with an aberrant right-sided aorta. The limitations of this case included increased operative difficulty because of less space in the left hemithorax and more difficulty in identifying and preserving the left recurrent laryngeal nerves and avoiding the heart.

The Patient

The patient is a seventy-three-year-old woman with a history of two prior paraesophageal hernia repairs with fundoplication with Collis gastroplasty and mesh placement. She presented with months of worsening debilitating nausea, vomiting, and dysphagia. Her workup demonstrated a nonfunctional and devitalized esophagus with a large recurrent hiatal hernia. Because of the significant impact of her symptoms on her quality of life, she was indicated for esophagectomy. Her preoperative CT scan demonstrated a right-sided aortic arch, a right-sided descending aorta, as well as an esophagus located to the left of the aorta and in the left hemithorax. 
 
The discussion around the patient’s operative approach was complex. The institution routinely performs esophagectomies using a minimally invasive three-field approach.  Additionally, the patient’s history of previous paraesophageal repairs precluded her from a transhiatal approach. Because of the unusual left-sided position of her esophagus, performing an intrathoracic anastomosis would have been possible but unnecessarily challenging. For these reasons, the surgery proceeded with a minimally invasive three field esophagectomy. She was indicated for a left-sided approach to esophageal mobilization rather than the usual right-sided approach because of her right-sided aorta as well as the location of her esophagus in the left hemithorax.
 
The Surgery

After anesthesia was induced, a preoperative esophagogastroduodenoscopy was performed, which identified a non-obstructed, dilated esophagus with a hiatal hernia. No masses or ulcers were identified. The stomach had pink mucosa, and the pylorus was visualized. The patient was then positioned in the right lateral decubitus position in anticipation of operating in the left hemithorax. 
 
A camera viewing port was placed in the eighth intercostal space in the posterior axillary line. The pleural space was examined, and a moderately sized hiatal hernia was identified with an esophagus that was to the left of the aorta. A utility port was made in the fifth intercostal space anteriorly, and a wound protector was placed. A third port was then placed in the seventh intercostal space anteriorly. The inferior pulmonary ligament was mobilized fully to the level of the inferior pulmonary vein. This dissection was continued along the posterior hilum, exposing the pulmonary artery and the aorta. 

Next, the posterior pleura between the esophagus and the aorta was opened with the harmonic scalpel to the level of the arch. The esophagus was noted to dive under the arch. The surgeons were able to get around the esophagus with a Penrose drain for retraction. The left recurrent laryngeal nerve as well as the vagus nerve were identified and preserved. Then, the esophagus was mobilized under the arch to the level of the thoracic inlet. 

A significant amount of time was taken to mobilize the esophagus and hiatal hernia from its adhesions to the pericardium, aorta, and contents of the right hemithorax, and care was taken to preserve the phrenic neurovascular bundle. The right pleural space was entered to ensure that the right lung was free from the hernia. The hiatal hernia was also cleared from the crura circumferentially. 

At this point, the surgeons were satisfied that they had obtained satisfactory esophageal mobilization for a tension-free cervical anastomosis. The abdominal and cervical portions of the case then proceeded without issue.
 
Postoperatively, the patient's hospital course was largely uneventful. She is recovering well at home with resolution of her preoperative nausea, vomiting, and dysphagia.

References

1. Ninomiya Y, Oguma J, Ozawa S, Koyanagi K, Kazuno A, Yamamoto M, Yatabe K. Thoracoscopic esophagectomy with left recurrent laryngeal nerve monitoring for thoracic esophageal cancer in a patient with a right aortic arch: a case report. Surg Case Rep. 2020 Mar 30;6(1):62. doi: 10.1186/s40792-020-00819-8. PMID: 32232599; PMCID: PMC7105558.
2. Okamura A, Watanabe M, Yuda M, Shoji Y, Yamashita K, Hayami M, Imamura Y, Mine S. Cervicothoracoscopic Approach for Esophageal Cancer in a Patient with Right-Sided Aortic Arch. Ann Surg Oncol. 2018 May;25(5):1287. doi: 10.1245/s10434-018-6355-3. Epub 2018 Feb 6. PMID: 29411200.
3. Takahashi K, Okamura A, Amada E, Otake R, Kozuki R, Toihata T, Imamura Y, Watanabe M. Esophagectomy for Esophageal Cancer in a Patient with Left Pulmonary Artery Sling. Ann Surg Oncol. 2020 May;27(5):1530. doi: 10.1245/s10434-019-08125-w. Epub 2019 Dec 12. PMID: 31832916.
4. Ujiie N, Nakano T, Kamei T, Ichikawa H, Miyata G, Onodera K, Ohuchi N. Thoracoscopic esophagectomy for esophageal cancer with situs inversus totalis: a case report and literature review. Gen Thorac Cardiovasc Surg. 2016 Jun;64(6):359-62. doi: 10.1007/s11748-016-0639-y. Epub 2016 Mar 16. PMID: 26984287.

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