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HOW I DO IT / HOW I DID IT SURGICAL PROCEDURES |
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ESOPHAGECTOMY
OPERATIVE TECHNIQUE: ¶Patient in supine position ¶Place a small sandbag under the patient’s right side to elevate that side 300, with right arm abducted and suspended from the "ether screen" cephalad to the surgical field ¶Turn the patient's head to left in case the right cervical region has to be exposed for the upper anastomosis ¶Prepare right neck, right hemithorax and abdomen ¶Perform a midline upper abdominal incision to initially explore the liver and lower esophagus ¶Make an incision along the course of 5th intercostal space from sternum to posterior axillary line in men. In women, make skin incision in the inframammary fold ¶Incise pectoral and anterior serratus muscles with electrocoagulator along the fourth interspace ¶Incise intercostal muscles along upper border of 5th rib ¶Divide internal mammary artery near the sternal margin between ligatures ¶Enter pleura of 4th intercostal space, and divide cartilaginous portion of 4th rib near its articulation with sternum ¶Clamp neurovascular bundle, divide it, and ligate with 2‑0 silk ¶Separate the ribs ¶Incise mediastinal pleura to expose esophagus ¶Identify, skeletonize, divide and doubly ligate azygous vein with 2‑0 silk ¶Encircle esophagus with finger at a point away from tumor ¶Divide several small arterial branches to the esophagus between ligatures ¶Dissect and include adjacent mediastinal lymph nodes in the specimen ¶Dissect esophagus from apex of chest to diaphragmatic hiatus ¶Do proximal gastric vagotomy ¶Ligate esophageal lumen proximal and distal to the tumor with narrow umbilical tapes ¶Cover thoracic incision with sterile towel ¶Mobilization of Stomach ¶Elevate sternum and left lobe of liver in a cephalad direction ¶Incise peritoneum overlying abdominal esophagus ¶Mobilize lower esophagus as in performing a vagotomy and transect vagal trunks and surrounding phrenoesophageal ligaments ¶Cephalad portion of gastrohepatic ligament is doubly clamped, divided, and ligated with 2‑0 silk ¶Elevate gastrophrenic ligaments and transect ¶Short gastric vessel identify, clamp, divide and ligate ¶Left gastroepiploic artery identify, clamp, divide and ligate ¶Divide greater omentum serially between clamps ¶Identify origin of left gastric artery at celiac axis ¶Divide coronary vein between 2‑0 silk ligatures ¶Divide left gastric artery between 2‑0 silk ligatures ¶Do an extensive Kocher maneuver o Incise peritoneum lateral to proximal duodenum, continuing until 3rd portion of duodenum o Divide lateral duodenal "ligament" behind descending duodenum ¶Dissect head of the pancreas from renal capsule, vena cava and aorta ¶Pull up pyloroduodenal segment high in the abdomen, 10cm from esophageal hiatus, allowing gastric fundus to reach thoracic apex, or neck, without tension ¶Pyloromyotomy o Make a 2cm incision across anterior surface of pyloric sphincter muscle o Separate bluntly the muscle fibers with a hemostat until mucosa bulges out ¶Ancement of Stomach into Right Chest o Divide right crux of diaphragm transversely using electrocautery and dilate esophageal hiatus manually o Advance stomach into right hemithorax o Suture wall of stomach to the margins of hiatus with interrupted 3‑0 silk o Expose esophagogastric junction in the right chest ¶Cear the areolar tissue and fat pad from the region of esophagocardiac junction ¶Apply a TA‑55 stapler to the gastric side of this junction and fire staples ¶Apply a clamp to the esophagus, which should be transected flush with TA‑55 stapler ¶Place an umbilical tape over divided esophagus ¶Esophagogastric Anastomosis o Select a point on proximal esophagus 10cm above the tumor for anastomosis o Before removing specimen, insert posterior layer of sutures to attach posterior esophagus to anterior seromuscular layer of stomach at a point 6cm from cephalad end of fundus, using interrupted 4‑0 silk Cushing sutures deep enough to catch submucosa o Transect posterior wall of esophagus 0.5cm beyond first line of sutures o Make a transverse incision in stomach and control the bleeding points o Approximate posterior mucosal layer with interrupted 4-0 silk sutures, with the knots tied inside the lumen o Pass NGT from proximal esophagus through the anastomosis into the stomach o Detach specimen by dividing anterior wall of esophagus, leaving anterior wall of esophagus 1cm longer than the posterior o Execute anterior mucosal layer by means of interrupted sutures of 4‑0 silk, with the knots tied inside the lumen, thus inverting the mucosa o Accomplish 2nd anterior layer by means of interrupted Cushing sutures of 4‑0 silk o Tack fundus of stomach to prevertebral fascia and mediastinal pleura at the apex of thorax with interrupted sutures of 3‑0 silk
¶Cervical Esophagogastric Anastomosis o In treating carcinoma of mid‑esophagus it is often necessary to resect entire thoracic esophagus, requiring an esophagogastric reconstruction in the neck o With patient's head turned slightly to the left, make an oblique incision along anterior border of right sternocleidomastoid muscle, carrying the incision through platysma o Identify and transect omohyoid muscle o Retract sternocleidomastoid muscle and carotid sheath laterally and retract the prethyroid muscles medially to expose thyroid gland o Middle thyroid vein, when present, should be doubly ligated and divided o Apply a TA‑55 stapler to the specimen side and transect the esophagus low in the neck flush with the stapler o Remove specimen through thoracic incision o Pass the fundus of stomach through the thoracic inlet into cervical region o Anchor it to prevertebral fascia with several 3‑0 cotton sutures o Insert posterior layer of sutures to attach posterior esophagus to anterior seromuscular layer of stomach at a point 6cm from cephalad end of fundus, using interrupted 4‑0 silk Cushing sutures deep enough to catch submucosa o Make a transverse incision in stomach and control the bleeding points o Approximate posterior mucosal layer with interrupted 4-0 silk sutures, with the knots tied inside the lumen o Pass NGT from proximal esophagus through the anastomosis into the stomach o Detach specimen by dividing anterior wall of esophagus, leaving anterior wall of esophagus 1cm longer than the posterior o Execute anterior mucosal layer by means of interrupted sutures of 4‑0 silk, with the knots tied inside the lumen, thus inverting the mucosa o Accomplish 2nd anterior layer by means of interrupted Cushing sutures of 4‑0 silk ¶Lavage operative site with saline solution ¶Place a Penrose drain out from prevertebral region through lower pole of incision ¶Approximate anterior border of sternocleidomastoid to strap muscles by inserting a layer of interrupted 3‑0 Vicryl sutures ¶Approximate the platysma using interrupted 3‑0 Vicryl sutures ¶Close the skin with continuous 4‑0 Vicryl subcuticular suture ¶Make a stab wound in the 7th intercostal space at the anterior axillary line ¶Insert a 36F chest tube through the stab wound and anchor it to the posterior pleura in the upper thorax with a 3-0 chromic catgut ¶Thoroughly irrigate thoracic and abdominal cavities with a saline solution ¶Approximate the ribs with 4 interrupted pericostal sutures of PDS-1 ¶Approximate serratus and pectoral muscles in layers by means of continuous 2‑0 Vicryl 2-0 ¶Close the skin with interrupted 3‑0 silk ¶Before closing the abdomen, insert a needle catheter feeding jejunostomy ¶Hemostasis ¶Layer by layer closure of the abdomen o Peritoneum and fascia closed as single layer using PG 0 continuous interlocking suture with interrupted silk 0 suture over the fascia every five continuous interlocking sutures o Subcutaneous tissue approximated using chromic 3-0 inverted T sutures o Ski9n closed by silk 3-0 interrupted sutures ¶Betadine ¶DSD ¶Patient tolerated procedure well |