Cadière G B, Torres R, Dapri G, Capelluto E, Hainaux B, Himpens J
Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium.
Surg Endosc. 2006 Aug;20(8):1308-9. doi: 10.1007/s00464-006-2020-1. Epub 2006 Jul 31.
Oesophagectomy with extended lymphadenectomy carries considerable morbidity due to parietal trauma. It is also technically extremely demanding because the difficult access even through a large thoracotomy requires the use of long instruments to reach the deepest recess in the chest cavity. Since the first thoracoscopic oesophagectomy reported by Cuschieri et al. [1] in 1992, different minimally invasive approaches have been proposed [2-12]. The aim of this video is to show the accurate and relative ease of an entirely thoracoscopic and laparoscopic oesophagectomy with an extended lymph node dissection of mediastinum in prone position (thoracoscopically) and celiac trunk (laparoscopically).
Oesophagectomy by thoracoscopy, laparoscopy and cervicotomy was proposed in a 63-year-old man with a lower third oesophageal cancer. General anaesthesia was performed with a double-lumen endotracheal tube and the patient was placed in prone position. Surgeons were positioned at the right side of the patient. Only three trocars were needed. A 10 mm 30-degree angled scope was inserted in the 7th intercostal space on the posterior axillary line and the remaining two 5 mm trocars were inserted in the 5th and 9th intercostal spaces on the posterior axillary line. Prone position allows an excellent visibility of the operative field even in an only partially deflated lung. In order to achieve a good exposure, transitory pneumothorax with CO2 (14 mmHg) was performed. The mediastinal pleura overlying the oesophagus was incised and the arch of azygos vein was isolated, ligated and divided. The oesophagus was circumferentially mobilized from the thoracic inlet down to oesophageal hiatus. Para oesophageal and subcarinal lymph nodes were dissected so as to remain in block with the surgical specimen. A 28 F chest tube was inserted in the 8th intercostal space on the anterior axillary line. In the second stage the patient was placed in supine position and pneumoperitoneum was established. Five trocars were placed along an ideal semicircular line, with the concavity facing the subcostal margin and a 30-degree angled laparoscope was used. The lesser omentum was widely opened up the right pillar of the hiatus. Mobilization of the greater curvature of the stomach was performed preserving the right gastroepiploic artery. A wide Kocher maneuver was performed. Celiac lymphadenectomy started with skeletonization of the hepatic artery until the root of left gastric artery was reached. This artery and the left gastric vein were dissected, clipped and sectioned. All fatty tissue and lymph nodes along hepatic artery, left gastric artery and celiac trunk were resected in block with the surgical specimen. Multiple applications of a linear endoscopic stapler were used to create the gastric tube. Finally the distal oesophagus was dissected, until the thoracoscopic dissection field was joined. In the third stage a left lateral cervicotomy was performed and the cervical oesophagus was dissected down to the thoracoscopic dissection plane. Oesophagus and stomach were delivered through the cervical incision and an oesophagogastric anastomosis was created by a linear stapler technique. Cervical and abdominal drainages were installed.
The total operative time was 271 minutes (thoracoscopy: 106 minutes, laparoscopy 120 minutes and cervicotomy 45 minutes) and blood loss was about 100 ml. Histological examination demonstrated a squamous cell carcinoma. Both margins of resection were free of tumour and 29 lymph nodes were retrieved. The final stage was IIA (pT3N0Mx).
Thoracoscopic and laparoscopic oesophagectomy with extended lymphadenectomy is technically feasible and safe. Thoracoscopic oesophagectomy in prone position improves the quality of dissection because: The oesophagus and aorto-pulmonary window are reached under excellent visibility, despite a partially deflated lung, which because of gravity will always remain out of harm's way. For the same reason small to moderate bleeding will not obscure the operative field. Dissection with the long endoscopic instruments is more accurate due to the support provided by the entrance site at the parietal level and the ergonomic position of surgeon. This article contains a supplementary video.
扩大淋巴结清扫的食管切除术因胸壁创伤而具有较高的发病率。由于即使通过大的开胸手术进入也很困难，需要使用长器械才能到达胸腔最深处，因此该手术在技术上要求极高。自1992年库斯基耶里等人[1]报道首例胸腔镜食管切除术后，人们提出了不同的微创方法[2 - 12]。本视频的目的是展示在俯卧位（胸腔镜下）和腹腔干（腹腔镜下）进行全胸腔镜和腹腔镜食管切除术并扩大纵隔淋巴结清扫的准确性和相对简便性。
对一名患有食管下段癌的63岁男性患者实施胸腔镜、腹腔镜及颈部切开食管切除术。采用双腔气管插管进行全身麻醉，患者取俯卧位。外科医生位于患者右侧。仅需三个套管针。在腋后线第7肋间插入一个10毫米30度角的内镜，其余两个5毫米套管针分别插入腋后线第5和第9肋间。俯卧位即使在肺仅部分萎陷的情况下也能提供极佳的手术视野。为了获得良好的暴露，采用二氧化碳（14 mmHg）进行短暂气胸。切开覆盖食管的纵隔胸膜，游离、结扎并切断奇静脉弓。将食管从胸廓入口向下至食管裂孔进行环形游离。清扫食管旁和隆突下淋巴结，使其与手术标本整块切除。在腋前线第8肋间插入一根28 F胸管。第二阶段，患者取仰卧位，建立气腹。沿理想的半圆形线放置五个套管针，凹面朝向肋缘下方，使用30度角的腹腔镜。广泛打开小网膜至裂孔右侧支柱。在保留胃网膜右动脉的情况下进行胃大弯的游离。进行广泛的科赫尔手法。腹腔淋巴结清扫从肝动脉骨骼化开始，直至到达胃左动脉根部。解剖该动脉和胃左静脉，夹闭并切断。将沿肝动脉、胃左动脉和腹腔干的所有脂肪组织和淋巴结与手术标本整块切除。使用线性内镜吻合器多次操作制作胃管。最后解剖食管远端，直至与胸腔镜手术区域相连。第三阶段，进行左侧颈部切开，将颈部食管解剖至胸腔镜手术平面。通过颈部切口引出食管和胃，采用线性吻合器技术进行食管胃吻合。放置颈部和腹部引流管。
总手术时间为271分钟（胸腔镜：106分钟，腹腔镜120分钟，颈部切开45分钟），失血约100毫升。组织学检查显示为鳞状细胞癌。切除边缘均无肿瘤，共获取29个淋巴结。最终分期为IIA期（pT3N0Mx）。
胸腔镜和腹腔镜食管切除术并扩大淋巴结清扫在技术上是可行且安全的。俯卧位胸腔镜食管切除术提高了清扫质量，原因如下：尽管肺部分萎陷，但由于重力作用，食管和主动脉 - 肺窗在极佳的视野下得以暴露，且始终不会受到损伤。同样原因，小至中等量出血不会遮挡手术视野。由于胸壁水平入口部位的支撑以及外科医生的人体工程学位置，使用长内镜器械进行清扫更为精确。本文包含一段补充视频。
