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The first 25 slides, exactly as they appear. The full deck has 163 content slides.
General Surgery
Video-Assisted Thoracic Surgery of the Esophagus
Built from Maingot's Abdominal Operations
What’s inside
12 sections · 163 slides
Overview
- Scope of this topic
- Terms used throughout
Rationale for Minimally Invasive Esophageal Surgery
Claims, criticisms and the supporting evidence
- Origins of minimally invasive foregut surgery
- Claims and criticisms of the keyhole approach
- Evidence in reflux disease and achalasia
- Status of minimally invasive thoracic esophageal surgery
- 8%
- Determinants of operative risk in esophagectomy
- Alternatives chosen when surgery looks too risky
- The appeal, and the caveat
- Evolution of technique since the first hybrid operations
- Reported advantages in the authors' experience
Esophageal Cancer and the Place of Surgery
Evidence from the definitive chemoradiation trials
- Management of resectable esophageal cancer
- Chemoradiation versus radiotherapy alone
- European trials of chemoradiation with or without surgery
- Consequences for practice and guidelines
Staging Esophageal Cancer
Limits of non-invasive imaging and the role of laparoscopy
- The case for invasive staging
- Evidence supporting laparoscopic staging
- Limitations of computed tomography
- Positron emission tomography in esophageal cancer
- PET for distant metastatic disease
- Endoscopic ultrasound
- Accuracy of the staging tests
- Standard staging sequence used by the authors
- Application of the staging pathway
- Abdominal port placement
- Reading the abdominal port map
- Laparoscopic staging: gaining access
- Laparoscopic staging: the five ports
- Laparoscopic staging: assessment of spread
- Preoperative conditioning of the esophagus
- Feeding access at the time of staging
- Selective use of thoracoscopic staging
- Thoracoscopic port placement
- Thoracoscopic staging steps
- Single-institution prospective staging series
- Multi-institution feasibility study
- Remaining questions about minimally invasive staging
- Molecular staging of node-negative disease
- Value of molecular node analysis
Choosing a Minimally Invasive Esophagectomy
Three routes and the case for the Ivor Lewis operation
- Minimally invasive esophagectomy: the available routes
- Determinants of approach selection
- Early hybrid operations
- Totally laparoscopic transhiatal esophagectomy
- Advantages and limits of the transhiatal route
- Adding a right thoracoscopic phase
- Results with the three-hole approach
- Complications of a cervical anastomosis
- Criteria favouring the Ivor Lewis approach
- Criteria favouring the Ivor Lewis approach (continued)
- Current preference and patient selection
Operative Technique: Laparoscopic Phase
Building the gastric conduit
- Positioning and airway set-up
- Sequence of the laparoscopic phase
- On-table esophagogastroduodenoscopy
- Laparoscopic access and port placement
- Consequence of the low port position
- Initial hiatal dissection
- Initial hiatal dissection
- Celiac lymph node dissection
- Gastric mobilization
- Freeing the upper stomach and hiatus
- Mobilizing the greater curvature
- Omental pedicle flap
- Creation of the omental pedicle flap
- Division of the left gastric pedicle
- Laparoscopic pyloroplasty
- Mobilization of the pyloric antral area
- Technique of the pyloroplasty
- Beginning the gastric tube at the lesser curve
- Creating the gastric conduit
- Exposure and staple alignment for the conduit
- Staple loads used along the conduit
- Completed gastric tube
- Conduit diameter and tip necrosis
- Lesson from conduit diameter
- Feeding jejunostomy
- Feeding jejunostomy technique
- Securing the jejunostomy
- Completion of the laparoscopic phase
- Attaching the conduit to the specimen
- Closing the abdominal phase
Operative Technique: Thoracoscopic Phase
Freeing the esophagus and building the chest join
- Repositioning for the chest phase
- Sequence of the thoracoscopic phase
- Operative set-up for the right-sided thoracoscopic phase
- Thoracoscopic port placement
- Diaphragm traction suture
- Thoracoscopic mobilization of the esophagus
- Starting the thoracic esophageal mobilization
- En bloc dissection towards the carina
- Lateral dissection and the thoracic duct
- Azygos vein and vagus nerve
- Extent of the upper mobilization
- Delivering the specimen and conduit into the chest
- Bringing the conduit into the chest
- Judging how much stomach to bring up
- Transection and specimen removal
- Creating the intrathoracic esophagogastric anastomosis
- Placing the anvil in the proximal esophagus
- Docking the stapler and firing the join
- Resection of the redundant gastric tube tip
- Closing the gastrotomy
- Completed anastomosis with omental pedicle wrap
- Omental wrap of the anastomosis
- Drainage and final steps
Outcomes and Complications
Findings from the published series
- The 222-patient three-hole series
- Case mix in the 222-patient series
- Completion and conversion
- Mortality in the 222-patient series
- Mortality and morbidity after minimally invasive versus open esophagectomy
- Reading the outcomes comparison
- Anastomotic leak and conduit diameter
- Recurrent laryngeal nerve injury
- Chylothorax
- Causes of delayed gastric emptying
- Delayed gastric emptying in practice
- Airway injury
- Survival and quality of life
- Rationale for abandoning the cervical anastomosis
- Published minimally invasive Ivor Lewis series
- Results of the authors' Ivor Lewis series
- Learning curve and exposure in the chest
Resection of Esophageal Leiomyoma
The commonest benign tumour of the esophagus
- Frequency and site of esophageal leiomyoma
- Layer of origin and growth pattern
- Symptoms of esophageal leiomyoma
- Indications for resection
- Risk of malignant change
- Choosing the access route
- Set-up and exposure for thoracoscopic enucleation
- Penrose drain used to expose an esophageal leiomyoma
- Exposing the tumour
- Thoracoscopic myotomy over the tumour
- Myotomy and enucleation
- Retrieval and leak test
- Closure of the myotomy
- Closing the myotomy
- Outcomes of thoracoscopic leiomyoma resection
- Tumour size and postoperative reflux
Achalasia and Other Indications
Comparative results of thoracoscopy and laparoscopy
- Achalasia and the shift to minimally invasive myotomy
- Preferred access for esophagomyotomy
- The theoretical case for a thoracoscopic myotomy
- Disadvantages of thoracoscopic myotomy
- Thoracoscopic versus laparoscopic myotomy outcomes
- Current place of thoracoscopic myotomy
- Thoracoscopic surgery for esophageal diverticula
- Reported results with diverticula
- The authors' diverticulum experience and conclusion
- Boerhaave syndrome and anastomotic leak repair
Summary
Key points from this topic
- Key points: staging
- Key points: technique
- Key points: outcomes
- Key points: benign disease
References
Source list from the original text
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- References (continued)
- Maingot's Abdominal Operations, 12th Edition