VATS Hand-Sewn Intrathoracic Esophagogastric Anastomosis

Introduction

Totally endoscopic two-stage (laparoscopic and VATS) esophagectomy for carcinoma of the lower third esophagus is a well-established procedure [1, 2]. There are currently many methods to perform an intrathoracic esophagogastric anastomosis by video-assisted thoracoscopic surgery (VATS) [3]. The technique described here is an extension of the technique used by T. Agasthian for VATS right upper lobe sleeve lobectomy for lung cancer [4]. Using the same VATS sleeve upper lobectomy incisions and technique, the hand-sewn intrathoracic esophagogastric anastomosis can be performed in a safe and simple way, and can be replicated by an experienced VATS surgeon.

Methods

Clinical Summary
The patient was a 64-year-old woman with a T2N0M0 adenocarcinoma of the lower third of the esophagus. Endoscopic imaging (EUS/OGD) showed a T2 cancer 35 cm from the incisions. Positron emission tomography–computed tomography showed no evidence of lymph node or distant metastasis.

Technique

Figure 1. Port placements.

The patient underwent a totally laparoscopic mobilization of the stomach conduit based on the left gastroepiploic vessels. Once the abdominal stage of the surgery was completed, the patient was turned to the left lateral decubitus position for the thoracic stage. The right lung was isolated with a left double-lumen endotracheal tube, and three incisions were made. A 5 mm camera port at the midaxillary line fifth intercostal space was followed by a 10 mm working port at the sixth intercostal space posterior axillary line and a 2 cm utility incision at the third intercostal space anterior axillary line (Ports A and B in Figure 1). An optional 5 mm retraction post can be placed at the sixth intercostal space, inferior and posterior to the scapular tip if needed (Port C in Figure 1). The surgeon and the camera assistant stand in front of the patient as in an anterior approach in VATS lobectomy (Figure 2). The operating table is rotated anteriorly towards the surgeon to a semiprone position to allow the lung to fall away from the operative field under gravity (Figure 3).

Figure 2. Operating room set up for VATS thoracic esophagectomy.

Figure 3. Position for VATS esophagectomy.

After opening the mediastinal pleura, the azygos vein is stapled and divided with a vascular stapler. A mediastinal lymphadenectomy is completed. The esophagus is encircled with a tape for retraction and is mobilized proximally and distally. The periesophageal hiatal attachments are divided, and the gastric conduit is delivered into the chest. The proximal esophagus and the distal gastric junction are divided with endostaplers at an appropriate level from the tumor for safe margins. The specimen is removed in an endobag by enlarging the cranial-most 10 mm port. The margins are confirmed to be negative for malignancy on frozen section, and the anastomosis is performed after ensuring there is no torsion with proper alignment of the conduit and esophagus (Video 1).

The anastomosis is done high up in the chest at the thoracic inlet to prevent conduit redundancy and reflux. The posterior wall of the proximal esophagus is tagged to the stomach with interrupted seromuscular sutures with polydiaxone (PDS) 4-0. The esophageal muscle layer is divided first, followed by the mucosal layer. This prevents retraction of the mucosal layer and ensures an accurate mucosal-to-mucosal anastomosis. The stomach is opened. An end-to-end esophagogastric anastomosis is done with interrupted 4-0 PDS sutures, starting in the center and working toward both ends. The sewing is done with a 5 mm endoneedle holder through Port B. This port is ergonomically ideal for sewing the anastomosis, as the needle holder and the direction of sewing is perpendicular to the esophagus and stomach anastomotic openings (Video 2). Once the posterior ends are completed, Connell stitches are inserted at both ends to ensure inversion and accurate mucosal apposition when connecting the anterior layer. A nasogastric tube is passed through the anastomosis and the anterior layer is completed with similar interrupted sutures. The last few anterior sutures are preplaced before tying. Tissue glue is applied over the anastomosis and a size F24 chest tube is placed (Video3).

Postoperative Management and Outcome

The patient made an uneventful recovery. An oral contrast swallow study on the seventh postoperative day showed no evidence of leak, with free flow of contrast into the small bowel. The final pathology showed a T2N1M0 adenocarcinoma of the lower esophagus with clear surgical margins, but two perigastric lymph nodes were positive for malignancy. The patient was referred for adjuvant chemotherapy.

Conclusion

We have performed this technique on 9 patients since 2014, with no leak or strictures to date. A totally hand-sewn intrathoracic esophagogastric anastomosis is a safe, replicable, and simplified technique which can be easily performed by most experienced VATS/laparoscopic surgeons. It allows for an accurate and wide mucosal-to-mucosal anastomosis between the esophagus and the stomach high up in the thoracic inlet, with safe oncological margins.

Preference card

1. 5 mm, 30 degree camera
2. 5 mm endoscopic needle holder
3. 4-0 polydiaxone (PDS) sutures
4. 5 mm endoscopic knot pusher

Tricks and Pitfalls

1. The first layer of seromuscular-anchoring sutures between the posterior wall of the esophagus and stomach are important for alleviating tension on the anastomosis and for proper alignment of the anastomosis without torsion.
2. It is important to perform a circumferential myotomy on the esophagus first and then to cut the mucosal layer long. This ensures the mucosal layer is longer than the muscle layer, prevents retraction of the mucosa into the esophagus, and allows for an accurate mucosal-to-mucosal anastomosis.
3. The corner Connell sutures are important in inverting the mucosal layer before the anterior portion of the anastomosis is performed.
4. It is mandatory to put port B in the third intercostal space. This gives direct perpendicular access to sewing of both ends. Removing the specimen by enlarging this incision facilitates sewing and tying.

References

1. Luketich JD, Pennathur A, Awais O, et al. Outcomes after minimally invasive esophagectomy: review of over 1000 patients. Ann Surg. 2012 Jul; 256(1):95-103.
2. Palanivelu C, Prakash A, Senthilkumar R, et al. Minimally invasive esophagectomy: thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone position--experience of 130 patients. J Am Coll Surg. 2006 Jul; 203(1):7-16.
3. Blackmon SH, Correa AM, Wynn B, et al. Propensity-matched analysis of three techniques for intrathoracic esophagogastric anastomosis. Ann Thorac Surg. 2007 May;83(5):1805–1813.
4. Agasthian T. Initial experience with video-assisted thoracoscopic bronchoplasty. Eu J Cardiothorac Surg. 2013 Oct; 44(4):616-623.