Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium.
Surg Endosc. 2010 Jun;24(6):1482-5. doi: 10.1007/s00464-009-0777-8. Epub 2009 Dec 24.
Only a few authors have reported the technique of Ivor Lewis esophagectomy by minimally invasive means, and anastomosis was usually performed by a circular stapler. We report an Ivor Lewis esophagogastrectomy with manual esogastric anastomosis performed by thoracoscopy in the prone position.
An adenocarcinoma of the distal esophagus without lymph nodes invasion was diagnosed in a 51-year-old man. General anesthesia and double-lumen endotracheal tube intubation were used. First the patient was placed in the supine position, and five abdominal trocars were placed. Celiac lymphadenectomy was performed with section of the left gastric vessels. A wide Kocher maneuver and pyloroplasty were performed. A wide gastric tube was performed and advanced through the hiatus into the right chest. Subsequently the patient was placed in the prone position. Three trocars (two 5-mm and one 11-mm) were placed on the posterior axillary line in the fifth, seventh, and ninth right intercostal space. The intrathoracic esophagus was dissected. Mediastinal lymphadenectomy with en bloc resection of the left inferior mediastinal pleura was performed. The azygos vein was sectioned, and the esophagus was transected by scissors 1-cm cranial to the azygos vein. A completely thoracoscopic manual double-layer anastomosis was performed by using running sutures with PDS 2/0 externally and Maxon 4/0 internally. Finally the patient was replaced in the supine position to retrieve the specimen through a suprapubic incision, and the gastric tube was fixed to the hiatus.
Thoracoscopy lasted 157' (anastomosis 40'), laparoscopy 160', and second laparoscopy 20'. Blood loss was estimated at 170 ml. The gastrograffin swallow on postoperative day 4 showed absence of stenosis and leak. The patient was discharged on postoperative day 6.
Thoracoscopy in the prone position allows the surgeon to perform a thoracoscopic esogastric anastomosis completely handsewn without selective lung desufflation, and using only three trocars.
仅有少数作者报道了微创手段行 Ivor Lewis 食管切除术的技术，且吻合通常使用圆形吻合器完成。我们报告了一例通过胸腔镜在俯卧位下完成的 Ivor Lewis 食管胃切除术及手工食管胃吻合。
一名 51 岁男性被诊断为下段食管腺癌，无淋巴结侵犯。全身麻醉和双腔气管插管。首先患者取仰卧位，放置五个腹部 Trocar。行腹腔干淋巴结清扫并离断胃左血管。行广泛 Kocher 操作和幽门成形术。制作一个宽大的胃管并通过食管裂孔进入右侧胸腔。随后患者取俯卧位。于右侧第 5、7 和 9 后肋腋前线分别放置三个 Trocar（两个 5mm 和一个 11mm）。游离胸腔内食管，整块切除左下心包。离断奇静脉，于奇静脉上方 1cm 处用剪刀横断食管。使用 PDS 2/0 缝线行全胸腔镜手工双层吻合，外缝线用 PDS 2/0，内缝线用 Maxon 4/0。最后患者仰卧位，经耻骨上切口取出标本，胃管固定于食管裂孔。
胸腔镜手术时间 157'（吻合 40'），腹腔镜手术 160'，二次腹腔镜手术 20'。估计出血量 170ml。术后第 4 天行胃造影未见狭窄和渗漏。术后第 6 天患者出院。
俯卧位胸腔镜允许外科医生在不选择性肺萎陷的情况下，仅使用三个 Trocar 完全行手工胸腔镜食管胃吻合。
