Laparoscopic Transhiatal Esophagectomy mayo stand and back table surgery setup

A Laparoscopic Transhiatal Esophagectomy is a minimally invasive surgical procedure used to treat esophageal cancer and strictures. It involves using a laparoscope and a few small incisions to remove part of the esophagus and reconnect it to the stomach. This technique has replaced the older three-incision method, resulting in lower complication rates and morbidity. This is typically done to treat cancer of the esophagus or to address other conditions that may affect the function of the esophagus. The surgery involves the use of a laparoscope and various instruments to access the esophagus and perform the necessary dissection, ligations, and anastomosis.

Positioning
Supine in reverse Trendelenburg with the entire neck, chest, and abdomen prepped

Equipment
Camera and light box, suction, CO2, surgeons preference staplers

Step 1: Port Placement
The first step of the procedure involves placing five ports. The initial port, a 12mm port, will be placed above the bellybutton for the laparoscope insertion. The insufflation tubing will then be attached, and a 30-degree laparoscope will be inserted. Two 5mm ports will be placed; one for liver retraction with the use of a liver retractor and the other for additional retraction. The remaining two ports will be 12mm ports for grasping and dissection.

Step 2: Dissection
After port placement, the lesser omentum is entered, and grasping instruments are used for dissecting tissue and nodes. The left gastric artery and vein are then ligated, which may involve using clips, L hook cautery, and laparoscopic scissors. More dissection will be done as required.

Step 3: Tubulization
The next step involves the use of a GIA stapler for gastric tubulization. The esophagus will be mobilized a little bit more, followed by more dissection, eventually leading to a cervicotomy and the esophagus being isolated.

Step 4: Anastomosis
The esophagus and gastric tubule (made with the stapler) will then be pulled through the cervicotomy, and an esophagogastric anastomosis will be performed.

Step 5: Closure
Finally, a nasogastric tube will be placed, followed by a feeding tube, and the incisions will be closed.

The Surgery Sparknotes

1. Place five ports: 12mm above bellybutton for laparoscope, two 5mm ports for retraction, and two 12mm ports for grasping and dissection.
2. Use grasping instruments for dissection of tissue and nodes.
3. Ligating left gastric artery and vein using clips, L hook cautery, and scissors.
4. Use GIA stapler for gastric tubulization and mobilize the esophagus.
5. Perform an esophagogastric anastomosis after pulling the esophagus and gastric tubule through the cervicotomy.
6. Place a nasogastric tube and feeding tube, and close the incisions.