Editing Oesophagectomy (section)

=== 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