Ivor Lewis Oesophagectomy

Approach
Generally Ivor Lewis over THE
- exposure and adequacy of LN dissection
- though no evidence; see card.
When proximal extension above the carina (24cm or above from incisors)
--> McKeown three-hole approach
--> i.e., esophagus mobilized in chest, then simultaneous in neck and abdomen.

Outline
1. Dissect GRJ
- expose crura; sharp dissection of peritoneum below inferior cardiophrenic vein.
2. Get R index finger around oesophagus, penrose drain around GEJ for retraction.
3. Preserve R gastroepiploic
- all inferior branches are divided by harmonic, staying 2cm from the vessel.
4. To L, take all short gastrics and come closer to serosa.
- occasionally reinforce short gastrics with hemoclips
5. L gastric artery and vein identified, LNs dissected.
- divide the vessels (e.g. with an endoscopic linear vascular stapler.
6. Point on lesser curvature taken, between 4-5th branches of the gastric arcade
- divide gastrohepatic omentum.
- multiple firings of the stapler used to create the conduit.
- can easily make a conduit that can reach the neck this way, by running parallel to GC.
7. Proximal tube goes toward apex of fundus; 5cm margin distal to GEJ.
- if radioRx, may need a 5cm margin from field for healing.
8. Feeding jej.
9. Lateral decubitus position for R thoracotomy through 5th intercostal space.
10. Pleura incised anterior to esophagus, along posterior edge of pericardium
- up to azygous arch and down to hiatus posteriorly along the aortic edge.
11. Get a finger around the oesophagus; penrose drain as retractor.
- alternately post and ant, separate from mediastinum including vessels.
12. Can include a cuff of diaphragm.
13. Do not deliver excessive length; S-shaped loop can cause dysphagia and pain.
14. Anastomosis, e.g. with hand-sewn mattress seromuscular and interrupted 3-0 PDS for mucosa.
- or side to side with stapler, anterior wall with hand sutures.
- or circular stapler, passed via a gastrotomy in the specimen.
15. Can do an intercostal muscle flap in an attempt to reduce leaks if preop chemorad.

Overall 5-yr survival <40%

Cameron 10th