Abdominal Phase of McKeown’s Esophagectomy: Laparoscopic D2 Dissection for Esophageal Cancer

Surgical Setup 

The surgical setup position utilized was low lithotomy with a 15-degree reverse Trendelenburg. General anesthesia was administered using a single-lumen tube, and an epidural infusion was provided for analgesia.  

For port placement, six ports were used in the laparoscopic procedure. An 11 mm port was inserted at the umbilicus for the camera. Additional ports included another 11 mm port at the right midclavicular line (MCL) and a 5 mm port at the left MCL. Two 5 mm ports were placed at the right and left hypochondriac (HC) regions, and a 5 mm epigastric port was used for liver retraction and further examination.  

Liver Retraction 

The Nathanson retractor was inserted via the epigastric port to elevate the left lobe of the liver. This exposed the gastrohepatic ligament and the hiatus, allowing for further dissection. 

Lesser Curvature Dissection, D2 Lymphadenectomy, and Vessel Division 

Dissection started along the lesser curvature with the division of the gastrohepatic ligament. Care was taken to carefully identify and preserve any replaced left hepatic artery. 

A comprehensive D2 lymphadenectomy was performed involving nodal clearance around several key structures: the common hepatic artery (CHA), left gastric artery (LGA), splenic artery, and celiac trunk. After achieving nodal clearance, the left gastric artery and vein were clipped and divided. The short gastric vessels and left gastroepiploic vessels were also divided to facilitate the full mobilization of the fundus and upper body of the stomach. This combined step ensured oncologic clearance and prepared the stomach for conduit formation. 

Hiatal Dissection 

The phrenico-esophageal ligament was divided and the lower esophagus was circumferentially mobilized at the hiatus, providing adequate length into the mediastinum. 

Greater Curvature Mobilization 

The gastrocolic ligament was divided to enter the lesser sac. Care was taken to preserve the right gastroepiploic arcade to maintain conduit vascularity and to avoid injury to the colon and mesocolon.

Pyloric Drainage Procedure (Optional) 

Depending on the surgeon’s preference, either pyloromyotomy or pyloroplasty may be performed to aid postoperative gastric emptying. 

Gastric Conduit Formation 

The stomach was tubularized along the greater curvature to create a gastric conduit, with the right gastroepiploic artery preserved as the primary blood supply. 

Conclusion

This structured abdominal phase of laparoscopic McKeown’s esophagectomy ensures safe exposure, radical lymphadenectomy, and optimal gastric mobilization for reconstruction. Clubbing nodal dissection with vessel division enhances procedural flow and aligns oncologic principles with technical execution. 

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