McKeown oesophagectomy and pulmonary wedge resection with a prone thoracoscopic and laparoscopic approach: a video report

Abstract

In the past few years, minimally invasive oesophagectomy has become an increasingly popular approach for oesophagectomy showing advantages in terms of fewer postoperative complications, shorter hospital stay and faster recovery. We present the case of a 60-year-old man with a lesion of the distal third of the oesophagus and solid pulmonary nodule who underwent McKeown subtotal oesophagectomy by laparoscopic and thoracoscopic approach in prone position with concomitant thoracoscopic pulmonary wedge resection. The postoperative course was smooth, and the patient was discharged on postoperative day 10. The procedure is feasible and safe, and combines better respiratory postoperative outcomes even when associated with other diagnostic or therapeutic lung procedures.

Background

Surgical resection plays a key role in the treatment of patients with oesophageal cancer. The introduction of minimally invasive oesophagectomy techniques has lowered postoperative morbidity and improved recovery and survival rates.¹ Among minimally invasive technique, thoracoscopic oesophagectomy in the prone position, first described by Cuschieri et al in 1994,² seems to be safe and technically feasible, and is associated with a lower mortality rate and a shorter hospital stay compared with open techniques.³ Advantages for prone decubitus in terms of respiratory complications, blood loss, exposure of the operative field and number of harvested lymph nodes have been advocated in comparison with other minimally invasive techniques.⁴

Case history

A 60-year-old man was admitted for progressive weight loss and dysphagia. A gastrografin swallow showed a small minus lesion of the distal third of the oesophagus. An endoscopy was performed, and a 5cm vegetative, ulcerated and bleeding lesion was found 25cm from the dental arch. Biopsies were taken, which demonstrated a moderately differentiated squamous cell carcinoma.

Staging computed tomography (CT) confirmed a tumour of the distal oesophagus with no extra-organ invasion. No lymphadenopathy or distant metastasis were present.

After multidisciplinary oncology team discussion, the patient underwent neoadjuvant chemoradiotherapy. A re-evaluation CT did not reveal signs of disease progression at oesophageal level but collaterally revealed the presence of an 8mm solid pulmonary nodule in the lateral segment of the right lower lobe, suspicious for primary lung cancer (Fig 1).

Figure 1. The nodule located in the right lower pulmonary lobe. The pathology examination was not conclusive. Given the radiological characteristics and the absence of other lymph node locations, we decided, together with the oncologist, to proceed with surgery.

A biopsy of the pulmonary nodule performed during the preoperative work-up was inconclusive at the pathology examination, so we decided to mark the nodule with ink and to perform a McKeown subtotal oesophagectomy by a laparoscopic and thoracoscopic approach in the prone position with concomitant thoracoscopic pulmonary wedge resection.

The intervention consisted of three stages (Video 1). The intervention began with the thoracic approach with the patient in prone position (Fig 2). A single-lumen endotracheal tube was used and the chest inflated with CO₂ to obtain a 7mmHg pneumothorax to partially collapse the right lung (Fig 3). After the oesophageal and lymph node dissections were performed, the pulmonary ligament was divided and we proceeded with the wedge resection of the 8mm pulmonary nodule previously marked. The procedure was performed with an endoscopic linear stapler using medium/thick cartridges and the pulmonary specimen was extracted using a laparoscopic retrieval pouch. After the thoracic stage, the patient was placed in a supine position to perform the laparoscopic mobilisation of the stomach and the dissection of coeliac trunk lymph nodes.

Figure 2. The prone position and trocar placement during thoracic stage. In the right hemithorax, two 12mm and one 5mm trocars were placed in the seventh intercostal space near the apex of the scapula, in the fifth space between the spinous process and the scapula and in the ninth space on the posterior axillary line, respectively.

Figure 3. Arrangement of organs during the thoracic stage (aorta in red, the spine in light blue, the azygos vein in blue, the vagus nerve in pink and the lung in yellow). The prone thoracoscopic approach allows a good exposure of the operative field for oesophageal dissection minimising the postoperative respiratory complications.

The first part of the cervical stage was then performed, beginning with the isolation and division of the cervical oesophagus. The specimen was then extracted through a mini-laparotomy and the gastric tube construction was carried out by multiple linear stapler firings. The gastric tube was therefore reintroduced into the abdomen and brought through the oesophageal hiatus to the neck and the intestinal continuity was restored by an end-to-side oesophagogastric anastomosis performed with a circular stapler.

The patient’s postoperative course was surgically uneventful. During the hospital stay, a gastrografin swallow and an endoscopy were performed. Both showed no signs of anastomotic leakage nor stenosis. Oral feeding was started on postoperative day 6 and the patient was discharged on postoperative day 10.

Pathology examination found a poorly differentiated ypT3N2 squamous cells carcinoma of the oesophagus (4/19 lymph nodes involved) and a benign mesenchymal neoplasm of the lung.

Discussion

Thoracoscopic oesophagectomy in the prone position shares the advantages of minimally invasive oesophagectomy techniques, only with a better exposition of the operative field without the need to totally collapse the lung (Fig 3). In this way, the related postoperative pulmonary morbidities such as pneumonia and atelectasis are reduced.³ Its low respiratory invasiveness allows for procedures otherwise not possible, such as minimally invasive oesophagectomy in a patient who has previously undergone a left pneumonectomy, as reported by Petri et al.⁵

Our case showed how thoracoscopic oesophagectomy in the prone position is possible and, during the same intervention, to carry out other diagnostic or therapeutic thoracic procedures, with only a slight increase in morbidity. The procedure is feasible and safe, and it combines better respiratory postoperative outcomes with the same oncological results than other minimally invasive oesophagectomy techniques.³ However, it should be performed in medium- to high-volume centre by skilled laparoscopic surgeons experimented in oesophageal surgery to further reduce the associated morbidity and mortality, with satisfying oncological results.