| 1 Exposure |
T1-1: Routinely use the Nathanson liver retractor, switch to a smaller size retractor after diving the LTL, optimize the retraction angle and only retract the part at the LTL |
SA1-1: Adequate mobility and suitable size of a retractor are required for better exposure |
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T1-2: Divide the LTL according to certain conditions |
SA1-2-1: There is a high risk of dividing the LTLSA1-2-2: Dividing the LTL provides better exposure and enough space for subsequent anastomosis |
DM1-2-1: If the division is difficult to perform, e.g., due to a plump left hepatic lobe, or a compacted LTL, consider leaving it un-divided. If there is a need for better exposure, only divide the part above the hiatusDM1-2-2: If the surgical field is already well-exposed, e.g., a wide sub-diaphragmic space, enough interval between the LTL and the hiatus, consider leaving it un-divided |
E1-2: Division risks injuring the surrounding structures including the liver and the diaphragm — R: SA1-2-1, SA1-2-2 |
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T1-3-1: Split the hiatus vertically for 1−1.5 cm |
SA1-3-1: The pericardium looks white and fibrotic, and is protected by surrounding adipose tissue.SA1-3-2: The adipose tissue surrounding the pericardium belongs to LN station No. 111.SA1-3-3: The purpose of splitting the hiatus is to determine the dissection plane. |
DM1-3-1: If there is not enough exposure, retracting the esophagus to form an angle between the diaphragm could help determine the position of the pericardium and further determine the direction of splitting the hiatus.DM1-3-2: Extend the splitting according to the exposure |
E1-3: Insufficient splitting impact the determination of the dissection plane, and subsequently, incomplete dissection — R: SA1-3-2, SA1-3-3, DM1-3-2 |
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T1-4: Retract the esophagus with a tape, optimize the retraction angle before passing the tape to the assistant, who should retract with moderate force |
SA1-4-1: Retracting the esophagus helps expose the infra-cardiac bursa, which is an important anatomic landmark.SA1-4-2: The retraction makes the anatomy of the lower mediastinum change accordinglySA1-4-3: Optimizing the angle before passing makes it easier for the assistant to assist even with less experience |
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T1-5: Hang both of the diaphragmatic crura with sutures, send the suture through the subcostal trocars or trocar wound closure device before fixation |
SA1-5-1: The purpose and timing of hanging the crura are for better exposure.SA1-5-2: Hanging the crura eliminates the need for retraction by the assistant.SA1-5-3: Adjust the suture to make better exposure before fixation |
DM1-5: If there is a wide sub-diaphragmic space, or the tumor has not invaded the EGJ, making a well-exposed surgical field, consider leaving the crura un-hanged or hanging one of the crura |
E1-5: The un-hanged or improperly hanged crura leads to a poorly-exposed surgical field and subsequent risk of diaphragmatic injuries during anastomosis —R: T1-5, SA1-5-1, SA1-5-3 |
| 2 Dissection |
T2-1: Unsophisticated surgeons should dissect in the sequence of anterior, right, posterior, and left. Skillful surgeons can adjust the route according to certain surgical conditions and personal habits |
SA2-1-1: Safety and efficiency of maneuvers should both be taken into account for the arrangement of the dissection route.SA2-1-2: Dissection of the anterior margin benefits the exposure of the side margins |
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E2-1: An improper route impact the exposure and increase the risk of pleural injuries — R: T2-1, SA2-1-1，SA2-1-2 |
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T2-2-1: Dissect the upper anterior of the esophagus and expand laterally for approximately 3 cm before reaching the pulmonary ligament. The superior margin is the lower pulmonary vein, but full exposure is not required.T2-2-2: Dissect the lower anterior of the esophagus. The inferior margin is the diaphragm |
SA2-2-1: There is no need to dissect LN station No. 112 completely. Exposure of the lower pulmonary vein requires dissection of pulmonary ligament, leading to higher risk than benefit.SA2-2-2: There is no need to dissect LN station No. 111 completely. Its upper limit is the adipose tissue surrounding the pericardium, not crossing the defined superior margin. The inferior caval opening is the right inferior limit of the LN station No. 111. The dissection only requires exposure of the caval opening. There is no need to expose the inferior vena cava |
DM2-2: If the tumor is located lower, the superior margin can be defined as the para-esophageal tissue 3 cm above the upper limit of the tumor, without crossing the pericardium. |
E2-2-1: Pleural injuries — R: SA2-2-1E2-2-2: Injuries to the inferior vena cava — R:SA2-2-2 |
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T2-3: Dissect the right side of the esophagus. The right margin is the right mediastinal pleura |
SA2-3-1: Consider denudation of the pleura as a marker of complete dissection. There is no need to dissect the pleura.SA2-3-2: The pleura is sheer and prone to be injured, especially with inadequate exposure, improper manipulation of energy devices, or over-retraction.SA2-3-3: Simple pleural injury does not impact postoperative recovery. The underlying purpose of pleural protection is to prevent lung injuries.SA2-3-4: The right pleura is protected by the infra-cardiac bursa, making it safe from injuries |
DM2-3-1: If the pleura is injured, choose from the following according to the severity and feasibility of repairment. (1) clipping (2) suturing with PROLENE (3) placing a chest tube without repairing |
E2-3-1: Pleural injuries — R: SA2-3-2E2-3-2: Lung injuries — R: SA2-3-3 |
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T2-4: Lift the esophagus at the intersection with the pericardium to enter the posterior space;Dissect vertically;Perform the lateral expansion moderately until reaching the pleura |
SA2-4: The bilateral pleural line could be well exposed with the retraction of the esophagus. Take care not to injure |
DM2-4: If the aorta is not exposed after moderate dissection, the direction of the dissection could be tilted and should be promptly adjusted |
E2-4: Pleural injuries — R: SA2-4, DM2-4 |
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T2-5: Dissect the left side of the esophagus. Keep close to the esophagus while dissecting. The left margin is the left mediastinal pleura |
SA2-5-1: Same as SA2-3-1SA2-5-2: Same as SA2-3-2SA2-5-3: Same as SA2-3-3SA2-5-4: The left mediastinal pleura adheres to the esophagus and is prone to be injured |
DM2-5-1: Same as SA2-3-1 |
E2-5-1: Pleural injuries — R: SA2-5-2, SA2-5-4E2-5-2: Lung injuries — R: SA2-5-3 |
| 3 Reconstruction |
T3-1: Perform esophago-jejunal/gastric anastomosis. The choice of anastomotic method is based on the location of the esophageal transection. Overlap reconstruction should be the first-line option |
SA3-1-1: Retraction of the esophagus impacts the estimation of the location of the transaction.SA3-1-2: The safety of the anastomosis is significant for postoperative recovery |
DM3-1-1: OrVil should be used after a higher esophageal transection.DM3-1-2: Difficulty from the trans-abdominal anastomosis prompt combined trans-thoracic surgery |
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T3-2: Perform jejuno-jejunal anastomosis through the assistive incision or intra-corporeally |
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DM3-2: Total laparoscopic surgery should be chosen for obese patients, dissecting the mesentery intracorporeally. If laparoscopic-assisted surgery is chosen, a longer assistive abdominal incision (12−15 cm) should be made |
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