Modified Technique for Abdominal Phase of Minimally Invasive McKeown Esophagectomy

Esophagectomy is associated with significant postoperative morbidity and mortality (1). In an effort to reduce these outcomes, many medical communities have adopted minimally invasive techniques for esophagectomy. A variety of minimally invasive techniques have been established (2,3). The authors’ center has been offering minimally invasive McKeown esophagectomy with extracorporeal gastric conduit formation since 2012, using a safe and straightforward eight-step technique for the abdominal component of the procedure. Patient positioning and port placement techniques are illustrated in the accompanying visual media.



Step 1: Liver Retraction

Surgeons use the "fan" retractor from the fifth port at the xiphoid process to retract the liver. Some surgeons use suturing techniques to retract the liver, but it takes some time. The fan retractor gives an excellent view without suturing.

Step 2: Opening the Gastrohepatic Ligament

The dissection starts at the gastrohepatic ligament and proceeds towards the right crus of the diaphragm along the gastrodiaphragmatic ligament. The right gastric artery is preserved at the site of the lesser curvature. With the help of the assistant, compression of the stomach improves surgical visualization of the vascular structures within the omental bursa. Circumferential dissection of the right and left crura, including complete division of the phrenoesophageal ligament, is performed.

Step 3: Abdominal Lymph Node Dissection

During the abdominal phase, a critical step is to begin the dissection by incising the peritoneum covering the pancreas and proceeding towards the common hepatic artery. Due to the presence of small vascular structures, great care must be taken to avoid unnecessary bleeding. The use of the Harmonic scalpel during this procedure offers significant advantages. The arterial sheath at the junction of the left gastric artery and the common hepatic artery is then opened, allowing extensive and safe dissection of the lymph nodes. While lymph node dissection around the celiac trunk is occasionally performed, this is not standard practice due to the low likelihood of metastasis. Paracardial nodes are always dissected.

Step 4: Management of the Left Gastric Vessels

After a complete dissection of the lymph nodes, surgeons can easily dissect the left gastric bundle. The left gastric artery is transected with Hem-o-lok clips or staplers.

Step 5: Management of Posterior Gastric Vessels and Adhesions

Retraction of the gastric fundus allows optimal visualization of the gastroesophageal junction and the esophageal hilum. Further dissection facilitates identification of the distal end of the esophagus, previously dissected in the thoracic phase. Increased mobilization may widen the esophageal hiatus and reduce the abdominal pressure resulting from carbon dioxide insufflation. According to the authors’ experience, this reduced pressure should not affect the subsequent surgical procedure.

Step 6: Management of the Short Gastric Arteries and the Splenic Hilum

The assistant surgeon performs appropriate lateral retraction of the stomach using a gauze band. Dissection of four to five rows of short gastric arteries and selected arterial branches from the splenic artery is performed with direct visualization of the spleen and its vasculature. Dissection continues along the gastric wall. The fundus of the stomach is delicate and prone to tearing if handled during the laparoscopic part of the procedure. Therefore, it is imperative to avoid contact with this region of the stomach.

Step 7: Dissection of the Gastrocolic Ligament Along the Greater Curvature by Mini Laparotomy

The skin incision below the subxiphoid process is extended to create the gastric conduit. The stomach is pulled up through the incision and the gastrocolic ligament is dissected, preserving the right gastroepiploic artery. To the right, the gastrocolic ligament is completely dissected to the proximal duodenum. On the left side, the gastrocolic ligament is completely divided.

Step 8: Creation of the Gastric Conduit

The gastric conduit is created extracorporeally using a linear stapler, taking care to maintain a width of 4 to 5 cm. The staple line is reinforced with a continuous 4-0 prolene suture. Hemostasis along the staple line is assessed and the viability of the gastric conduit is assessed. A feeding jejunostomy is then created.

In conclusion, this modified technique provides a safe operating environment and is easily reproducible and learnable for thoracic surgeons with limited laparoscopic experience. By eliminating the possibility of touching or clamping the gastric conduit throughout the procedure, it minimizes the risk of conduit injury. It also provides better exposure of the splenic hilum and reduces the likelihood of splenic injury. In addition, it has the potential to reduce overall operative time.

References

1. Hao Wang, Han Tang, Yong Fang, Lijie Tan, Jun Yin, Yaxing Shen, et al. Morbidity and Mortality of Patients Who Underwent Minimally Invasive Esophagectomy After Neoadjuvant Chemoradiotherapy vs. Neoadjuvant Chemotherapy for Locally Advanced Esophageal Squamous Cell Carcinoma: A Randomized Clinical Trial; JAMA Surg. 2021 May 1;156(5):444-451.
2. Shawn S Groth, Bryan M Burt. Minimally invasive esophagectomy: Direction of the art. J Thorac Cardiovasc Surg. 2021 Sep;162(3):701-704.
3. van der Sluis PC, Schizas D, Liakakos T, van Hillegersberg R. Minimally invasive esophagectomy. Dig Surg. 2020; 37(2):93-100.

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