Technique of Minimally Invasive Ivor Lewis Esophagectomy

Although a variety of surgical techniques exist for esophageal resections, the two most common approaches are the transhiatal esophagectomy and the Ivor Lewis esophagectomy. The choice of the most suitable operation takes into consideration several factors including the location of the tumor; the patient's medical condition, body habitus, prior surgical history, and history of radiation therapy; the organ to be used as a replacement conduit; the limits of node dissection; and finally, the surgeon's preference.Despite evolving techniques and improvements in both the transhiatal and the Ivor Lewis surgical approaches, esophagectomies are complex operations that are associated with significant morbidity and mortality. Furthermore, surgical candidates are often elderly patients with coexisting medical comorbidities including respiratory and cardiovascular diseases. Nationwide, the mortality rates from esophagectomies range from 8% in high-volume centers to as high as 23% in low-volume centers. ¹ Therefore, to limit the physiologic stress and inflammatory responses associated with open esophagectomy, minimally invasive surgical approaches have been developed. ^{2, 3, 4, 5} This paradigm shift has been driven by the observation that minimally invasive surgery is associated with equal efficacy, less pain, and an earlier return to work as compared with open surgery. Minimally invasive esophagectomy can be preformed via transhiatal, modified McKeown, and Ivor Lewis approaches.In our initial experience, we utilized a three-field, laparoscopic-thoracoscopic approach. Our earlier publications with this technique demonstrated that minimally invasive esophagectomy could be performed safely with equivalent stage-specific survival compared with the larger open series in the existing literature. ² Although technically demanding and associated with a significant operator learning curve, data from our series revealed a decrease in operative blood loss, length of stay, pulmonary complications, and narcotic requirements. In both our own experience and publications elsewhere, concerns have arisen regarding an increased incidence of technical complications associated with cervical esophagogastric anastomoses including anastomotic leak, stricture, recurrent laryngeal nerve injury, and pharyngoesophageal swallowing dysfunction. In light of these concerns, we have evolved our technique to a completely laparoscopic-thoracoscopic (Ivor Lewis) esophagectomy with complete lymph node dissection for typical gastroesophageal junction tumors. Unless contraindicated by tumor location or previous thoracic surgery, we presently favor the totally minimally invasive Ivor Lewis approach.

The decision of which minimally invasive approach to use is based on the location and extension of the tumor and the experience of the surgeon with a particular technique. The superior results of the minimally invasive Ivor Lewis approach are attributed to the following: (1) the avoidance of a neck dissection, thereby lowering the potential for recurrent laryngeal nerve injury and microaspiration; (2) the ability to extend the resection onto the stomach and gastric cardia to obtain negative margins for tumors in the gastroesophageal junction; (3) adequate length of the tubularized gastric conduit, thereby decreasing tension on the anastomosis; (4) the ability to amputate the most proximal tip of the newly constructed gastric conduit, which is the most susceptible to ischemia and potential leak; and (5) the ability to perform the anastomosis with a wide view within the chest cavity.As with all esophageal procedures, the surgeon must be experienced in several surgical options as a variety factors (tumor extension, body habitus, and prior surgery) often dictate the surgical approach. It clearly has been demonstrated that minimally invasive esophageal resections are technically feasible and can be performed as safely as conventional esophagectomies. However, we believe that minimally invasive esophageal surgery should be performed in high-volume centers with significant experience in both open and minimally invasive approaches to optimize patient safety and outcome.