Ivor Lewis esophagectomy with manual esogastric anastomosis by thoracoscopy in prone position and laparoscopy

Only a few authors have reported the technique of Ivor Lewis esophagectomy by minimally invasive means, and anastomosis was usually performed by a circular stapler. We report an Ivor Lewis esophagogastrectomy with manual esogastric anastomosis performed by thoracoscopy in the prone position. An adenocarcinoma of the distal esophagus without lymph nodes invasion was diagnosed in a 51-year-old man. General anesthesia and double-lumen endotracheal tube intubation were used. First the patient was placed in the supine position, and five abdominal trocars were placed. Celiac lymphadenectomy was performed with section of the left gastric vessels. A wide Kocher maneuver and pyloroplasty were performed. A wide gastric tube was performed and advanced through the hiatus into the right chest. Subsequently the patient was placed in the prone position. Three trocars (two 5-mm and one 11-mm) were placed on the posterior axillary line in the fifth, seventh, and ninth right intercostal space. The intrathoracic esophagus was dissected. Mediastinal lymphadenectomy with en bloc resection of the left inferior mediastinal pleura was performed. The azygos vein was sectioned, and the esophagus was transected by scissors 1-cm cranial to the azygos vein. A completely thoracoscopic manual double-layer anastomosis was performed by using running sutures with PDS 2/0 externally and Maxon 4/0 internally. Finally the patient was replaced in the supine position to retrieve the specimen through a suprapubic incision, and the gastric tube was fixed to the hiatus. Thoracoscopy lasted 157' (anastomosis 40'), laparoscopy 160', and second laparoscopy 20'. Blood loss was estimated at 170 ml. The gastrograffin swallow on postoperative day 4 showed absence of stenosis and leak. The patient was discharged on postoperative day 6. Thoracoscopy in the prone position allows the surgeon to perform a thoracoscopic esogastric anastomosis completely handsewn without selective lung desufflation, and using only three trocars.