Uniportal video-assisted thoracoscopic Ivor Lewis oesophagectomy

Abstract

Standard minimally invasive Ivor Lewis oesophagectomy is performed through a multiport technique using carbon dioxide. However, access to video-assisted thoracoscopic surgery (VATS) is increasingly shifting to a single-port approach due to its proven safety and efficacy in lung surgeries. Therefore, the preamble of this submission is to describe, ‘How I do differently’ uniportal VATS MIO in three major steps: (a) VATS dissection through a single 4-cm incision in a semi-prone position without artificial capnothorax; (b) fluorescence dye to check conduit perfusion and (c) intrathoracic overlay anastomosis with a linear stapler.

INTRODUCTION

Oesophagectomy is the cornerstone in the multimodality treatment of oesophageal cancer. The open approach for this surgery is the time-tested benchmark procedure against which minimal access techniques have proven superior in terms of post-operative recovery with similar oncological outcomes.[1] Conventionally, the thoracic dissection phase is performed using multiple ports during video or robotic minimally invasive oesophagectomy (MIO) creating an artificial capnothorax. However, recently uniport resection techniques have been tried by a few surgeons for doing surgeries on mediastinal structures, including the oesophagus.[1-3] Here, we describe how we perform minimal access Ivor Lewis (IL) oesophagectomy differently in the semi-prone position.

TECHNICAL DETAILS

A 60-year-old male patient was evaluated for Grade II dysphagia. Endoscopy showed negotiable proliferative oesophageal growth from 35 to 39 cm, which was reported as squamous cell carcinoma on biopsy. Imaging showed locally advanced disease (cT3, N+). After the discussion in the multidisciplinary meeting, he was put on the neoadjuvant CROSS protocol (41.4 Gy). He showed an excellent response to the treatment with minimal uptake on imaging only at the primary site (Standard Uptake Value (SUV) = 3.8). Uniportal video-assisted thoracoscopic surgery (uVATS) IL oesophagectomy was planned 6 weeks after chemoradiotherapy. First, the abdominal phase was performed by conventional multiport technique, creating about 4-cm wide stomach conduit and feeding jejunostomy. Then, the endotracheal tube was replaced by a double-lumen tube, and subsequently, the patient was turned 45° semi-prone with the right side up [Figure 1]. The right lung was isolated, and the thoracic phase started with a 4-cm incision at the right 6^th intercostal space, anterior to the posterior axillary line. After entering the chest cavity, a wound protector (2.5–6 cm) was placed through this incision for all instrumentation, including a 5-mm camera. The pleural cuts were given above and below the azygous vein, and the latter was ligated [Figure 2a]. Oesophagus was looped after mobilisation from the pericardium anteriorly and the aorta posteriorly. Standard infracarinal two-field lymphadenectomy was performed. After this, the oesophagus was divided with the linear stapler at the appropriate level of the azygous vein [Figure 2b]. The specimen was pulled superiorly to bring the stomach into the chest [Figure 2c]. Next, 4-mg indocyanine green (ICG) was injected intravenously to inspect the perfusion of the conduit, which was cut with the stapler at a suitable level, and the specimen was removed [Figure 3a-c]. The oesophageal stapled line was also opened at one end, through which the nasogastric (NG) tube was pulled into the chest [Figure 3d]. Further, the anastomotic site was marked 5 cm from the proximal conduit end and opened with cautery [Figure 4a]. Stay sutures were taken between the oesophagus and the stomach for alignment. Next, a 45-mm purple articulating linear stapler was introduced with the placement of one limb into the stomach opening and the other into the oesophageal opening while withdrawing the NG tube to ensure the stapler’s proper placement inside the oesophagus lumen [Figure 4b and c]. After the side-to-side anastomosis was created, the NG tube was advanced into the stomach. Further, the common wall was sutured using two layers of two V-Loc™ 3-0 (Medtronic, CA, USA) absorbable sutures. A leak test was done by pushing methylene blue through the NG tube [Figure 4d and e]. The chest tube was placed, and the incision was closed in three layers [Figure 5a]. The patient was extubated in a supine position and shifted to the ward. The post-operative phase was uneventful. Chest tubes were removed on day 6 after confirming no leak on contrast X-ray [Figure 5b]. He was allowed orally and sent home on day 8. Final histology showed only dysplastic mucosa at the stricture site. Currently, he is doing well at 60-day follow-up.

Figure 1.

Patient positioning and camera setup at the operating table. ICG: Indocyanine green, PAC: Posterior Axillary Crease / fold/line

Figure 2.

(a) Azygous vein ligation and division, (b) Intrathoracic oesophageal division with a linear stapler, (c) Delivery of stomach conduit in the chest

Figure 3.

(a) ICG perfusion in contrast mode, (b) ICG perfusion in colour-segmented mode, (c) Division of stomach and specimen delivery, (d) NG tube delivery from oesophageal opening into the thorax. ICG: Indocyanine green, NG: Nasogastric

Figure 4.

(a) Anastomosis site marking, (b) Advancing one limb of the linear stapler into the stomach, (c) Advancing the second limb of the linear stapler into the oesophagus, (d) Checking anastomosis leak, (e) Completed anastomosis

Figure 5.

(a) Patient positioning at the chest closure, (b) Post-operative X-ray shows no contrast leak across the anastomosis

BENEFITS

MIO is performed either by VATS or robotically. Conventionally, the thoracic phase requires multiple ports and carbon dioxide insufflation. Therefore, during IL oesophagectomy, a port is enlarged to retrieve the specimen. In addition, intrathoracic anastomosis is performed using a circular or linear stapler with a T-shaped side-to-side configuration.

uVATS approach is well standardised for lung surgeries. In addition, its feasibility has been recognised recently for both benign and malignant oesophageal disorders.[1] uVATS technique can be performed by a small 3–5-cm incision without rib spreading for doing IL MIO.[1,3] Both the surgeon and the assistant stand on the same side with the camera screen on the opposite side. In addition, the semi-prone position omits the need for lung retraction and avoids blood pooling away from the site of dissection.[4] This provides all the advantages of minimal access and early post-operative recovery with minimal analgesic need. Artificial capnothorax is not required. Camera fogging is minimal as suction is continuously on and can also be used as a retractor. The specimen is removed without enlarging or creating any additional ports.[1,2]

In addition, a side-to-side overlay anastomosis can quickly be done with a linear stapler through this single port.[1] The advantage of using an articulating linear stapler is that the incision site on the chest need not be modified, whether anastomosis is at the azygous level or the apex of the chest. ICG is beneficial in checking the conduit perfusion and marking the anastomosis site.[5] A trained camera assistant is crucial for uniport surgery though it has a short learning curve because the hands, eyes and target lie on the same axis, compared to the multiport method. We believe that uVATS IL MIO is a quick, safe technique and can be reproduced reliably. However, the long-term results are necessary to compare the oncological outcomes against the established multiport procedure.

Declaration of patient consent

The authors certify that they have received appropriate patient consent to use his intraoperative images and other clinical information for reporting in the journal. The patient understands that the authors will make all efforts to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.