Department of Upper Gastrointestinal Surgery, Mercy University Hospital, Cork, Ireland
Abstract: Ivor-Lewis oesophagectomy is the standard treatment for resectable oesophageal carcinoma, although it is associated with significant postoperative morbidity and mortality. Minimally invasive oesophagectomy (MIO) is increasingly adopted as the preferred surgical approach in order to decrease perioperative morbidity and facilitate earlier functional recovery. (I) stage I: with the surgeon on the right and the assistant on the left a 5-port technique is used to perform a laparoscopic gastric mobilisation with an en bloc lymphadenectomy of the common hepatic, left gastric and splenic artery lymph node stations. The stomach is fully mobilized with preservation of the right gastroepiploic arcade. After full mobilisation of the stomach a 3.5–4 cm gastric conduit is fashioned by sequential firing of an EndoGIA 4.8-mm stapler. The gastric conduit is then sutured to the transected stomach for retrieval later in the chest. A Heineke-Mikulicz pyloroplasty is fashioned in selected cases. Using a seldinger technique a 9-Fr feeding jejunostomy is inserted into the jejunum and secured to the anterior abdominal wall with a purse-string suture. (II) Stage II: a 5-post thoracoscopy is performed in the left lateral decubitus position. The oesophagus is fully mobilized to the thoracic inlet and an en bloc lymphadenectomy is performed of the paraesophageal, subcarinal, right and left bronchial and lower paratracheal lymph node stations. The 9th intercostal port site is converted to a 3–4 cm mini-thoracotomy. A 28 mm circular anvil is placed in the proximal oesophagus and secured with a purse-string suture. A gastrotomy is made in the tip of the gastric conduit through which an EEA circular stapler is inserted. An esophagogastric end-to-side anastomosis is fashioned and the redundant fundal tissue excised with a linear stapler. A 16 French chest tube is placed prior to closure of the wounds. MIO has been successfully implemented in the Mercy University Hospital with a median length of stay of 8 days and an in-hospital mortality of 3.5%.