Editing Oesophagectomy (section)

== '''Right-sided Ivor Lewis approach:''' ==

=== Abdomen: ===

** Midline laparotomy
** Check for metastases
** Prepare gastric tube
*** Start on greater curvature       - identify right gastroepiploic arcade near the midpoint of greater       curvature and start dividing the omentum 2cm peripheral, working towards       the fundus, preserving the arcade for the conduit
*** Divide short gastrics 1cm       off the stomach, and separate stomach from splenic hilum
*** Incise phreno-oesophageal       ligament
*** Identify left gastric       artery (elevate stomach towards hiatus and look for the band of fat       between retroperitoneum and lesser curvature. Left gastric dissected and       ligated (using EndoGIA tan 45mm), with resection of lymphatics around       it. Avoid splenic artery near origin of left gastric artery.
*** Lesser omentum opened
*** Divide hepatic branches of       the vagal nerves
*** Right gastric artery       divided close to pylorus
*** Identify resection margins       required - aim for 10cm distal to known tumour
*** Fashion a 4-5cm gastric       tube using linear staplers (narrower tubes have better emptying, whereas       wide tubes retain better perfusion). Start on greater curvature at level       of division, then work on an oblique line towards incisura/pylorus.
*** Kocher manoeuvre - pylorus       should reach caudate lobe when the conduit is pulled up
*** Consider       pyloroplasty/pyloromyotomy - Incise over pylorus, then spread muscle       fibres, trying to avoid using diathermy.
** Mobilise left hepatic lobe      (divide falciform ligament and left triangular ligament, and incise pars      flaccida)
** Finalise dissection of the      oesophagus - expose the junction of left and right crura posteriorly
** Suture the two halves of      stomach together with 3x interrupted, so they can be pulled up into the      chest.
** Remove all nodes from      coeliac axis, and along splenic artery to splenic hilum
** Clear common hepatic nodes      up to IVC and PV
** Place jejunostomy 40cm      distal to ligament of Treitz
** 24Fr Blakes drain alongside      pylorus

=== Thorax: ===

** Positioned left lateral      decubitus
** Thoracotomy in 5th      intercostal space, with resection of part of rib, and rib spreader
** Exposure:
*** Retract right lung to       expose thoracic oesophagus
*** Incise right inferior       pulmonary ligament and remove level 9 nodes
*** Continue dissection along       the posterior hilum, past the right mainstem bronchus up to arch of       azygos
*** Ligate and divide azygos       vein (not always done for GOJ tumours)
** Oesophagus mobilised with      all surrounding tissues - en bloc resection, including thoracic duct,      subcarinal and paraoesophageal lymph nodes together with oesophagus
*** Dissect between pericardium       and oesophagus, continuing superiorly and laterally
*** Then dissect posteriorly,       being sure to take the thoracic duct
*** Divide and ligate all       oesophageal arterial branches and venous tributaries
*** Dissect as far down as the       oesophageal hiatus and as far up as the carina
*** Isolate thoracic duct in       the top of the chest (where it crosses posteriorly from right to left       near the arch of the azygos) and above the diaphragm, clip and transect       it
** Once superior to the arch of      azygos, should stay directly on the oesophageal wall to avoid RLN injury,      especially once you get up towards the thoracic inlet
*** Remove paratracheal nodes       and fatty tissue, aware of right recurrent nerve
**** Can do frozen section        here, proceeding to three-field lymphadenectomy if positive
*** Remove aortopulmonary and       left recurrent nodes too
** Divide oesophagus around      level of azygos arch, although can be higher or lower
** Anastomosis in chest
*** Make small oesophagotomies       and insert 45mm EndoGIA purple to create a side-to-side anastomosis
*** NGT passed distally to       hiatus, sutured to nose
*** Complete anterior wall with       interrupted 3/0 PDS
*** Leak test with 100mL air
*** Cover with pleura/fat
** 10Fr silastic drain      alongside anastomosis
** 28Fr ICC
** Close chest