Müller-Stich Beat, Schmidt Thomas, Nienhüser Henrik, Nickel Felix, Billeter Adrian, Diener Markus, Ulrich Alexis, Büchler Markus W
Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld, 69120, Heidelberg, Deutschland.
Chirurg. 2020 Dec;91(Suppl 1):13-14. doi: 10.1007/s00104-020-01152-4.
Esophagectomy for oncological reasons is associated with high morbidity, which was intended to be reduced by a minimally invasive approach. Main problem of the minimally invasive approach is the challenge of a safe intrathoracic anastomosis. To address this problem several methods such as a collar anastomosis instead of an intrathoracic anastomosis with poor functional outcome, hybrid techniques with an open approach to the demanding intrathoracic circular stapled anastomosis ore robotic assistance have been used. We demonstrate the minimally invasive linear stapler technique for the intrathoracic esophagogastrostomy, which can be applied quite easily even without robotic assistance.
The abdominal part is performed with the patient in French position. After division of the greater omentum along the gastroepiploic arcade and the spleen as well as the perigastric incision of the lesser omentum 6cm from the pylorus a 4,5 cm gastric conduit is created in linear stapler technique. Next an intraabdominal and transhiatal systematic lymphadenectomy is performed. For the thoracic part the patient is repositioned in a left side position. The thoracic lymphadenectomy is completed, and the specimen removed via mini-thoracotomy. For the anastomosis the esophageal stump is incised, and the gastric conduit is opened 5 cm from the oral resection line. Once the stapler is fired and removed the remaining opening is hand-sewn in a modified double-layer technique.
The side-to-side esophagogastrostomy in linear stapler technique seems to be a quite easily feasible and safe alternative for the reconstruction after minimally invasive esophagectomy. To confirm this, the method is currently investigated in a randomized controlled trial.
出于肿瘤学原因进行的食管切除术与高发病率相关，微创方法旨在降低发病率。微创方法的主要问题是安全的胸内吻合术面临挑战。为解决这一问题，已采用了多种方法，如采用功能效果不佳的颈部吻合术替代胸内吻合术、采用开放方法进行要求较高的胸内圆形吻合器吻合术的混合技术或机器人辅助技术。我们展示了用于胸内食管胃吻合术的微创线性吻合器技术，即使在没有机器人辅助的情况下也能很容易地应用。
腹部手术部分在患者处于法国体位时进行。沿胃网膜动脉弓和脾脏分离大网膜，并在距幽门6cm处进行小网膜的胃周切口后，采用线性吻合器技术制作一个4.5cm的胃管。接下来进行腹腔内和经裂孔的系统性淋巴结清扫术。对于胸部手术部分，患者重新定位为左侧卧位。完成胸部淋巴结清扫术，并通过小切口开胸取出标本。对于吻合术，切开食管残端，在距切缘5cm处打开胃管。一旦吻合器击发并取出，剩余开口采用改良双层技术手工缝合。
线性吻合器技术的侧侧食管胃吻合术似乎是微创食管切除术后重建相当容易实施且安全的替代方法。为证实这一点，目前正在一项随机对照试验中对该方法进行研究。
