Standardized Operative Approach for Total Minimally Invasive Ivor Lewis Esophagectomy in Hostile Abdomen

Total minimally invasive Ivor Lewis esophagectomy can be a feasible approach in patients with history of multiple intraabdominal surgeries, as demonstrated in the video below. This suggests generalizability of the authors’ approach to improve the surgical treatment of esophageal cancer.

The Patient

The patient had a history of multiple intraabdominal surgeries and needed to undergo a minimally invasive Ivor Lewis esophagectomy. This video reflects the recently described completely minimally invasive esophagectomy (MIE) and perioperative care (1) of the authors’ integrated health system. 

The patient is a seventy-six-year-old woman with a previous Hartmann’s procedure and subsequent colostomy takedown for perforated diverticulitis. She had clinical stage IIB (T3N0M0) Siewert I gastroesophageal junction (GEJ) adenocarcinoma status post neoadjuvant chemoradiation in accordance with the CROSS protocol. A standardized total minimally invasive Ivor Lewis esophagectomy was able to be performed safely and successfully despite the patient’s surgical history. 

The Surgery

The procedure began with an abdominal approach, first defining the GEJ. It then continued with careful dissection to fully mobilize the stomach and dissect the hiatus. Tubularization along the lesser curve of the stomach began but was not yet completed. The surgeons did not routinely perform feeding access or pyloroplasty. 

The team then moved to the thoracic portion of the procedure. It should be noted that the pleural dissection performed included preservation of the posterior mediastinal pleural envelope to facilitate its closure at the end of the operation. Once the esophagus was fully mobilized and divided, the distal esophagus and gastric conduit were retrieved to complete the intrathoracic anastomosis. Tubularization of the stomach was then completed. The mediastinal envelope was closed, and intercostal nerve blockade was performed with liposomal bupivacaine. 

Postoperative Course

The patient tolerated the procedure well and followed standard postoperative protocol. She was discharged home on postoperative day two with a Blake drain in the right chest. She was advanced to a full liquid diet on postoperative day five. Her drain was removed after two weeks in clinic, and she advanced to regular diet. 

References

1. Ashiku SK, Patel AR, Horton BH, Velotta J, Ely S, Avins AL. A refined procedure for esophageal resection using a full minimally invasive approach. J Cardiothorac Surg. 2022;17:29. doi:10.1186/s13019-022-01765-2

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