Simplifying Minimally Invasive Transhiatal Esophagectomy With the Inversion Approach

Abstract

The laparoscopic transhiatal esophagectomy can be simplified and performed safely and effectively by using a novel esophageal inversion technique.Design: Case series describing technique, initial experience, and learning curve with laparoscopic inversion esophagectomy.Setting: Tertiary care university hospital and veteran's hospital.Patients: Twenty consecutive patients with highgrade dysplasia (n = 16) and esophageal adenocarcinoma (n=4).Intervention: Laparoscopic inversion esophagectomy, a totally laparoscopic approach to transhiatal esophagectomy that incorporates distal to proximal inversion to improve mediastinal exposure and ease of dissection.Main Outcome Measures: Perioperative end points and complications, compared between the first and second groups of 10 patients.Results: There were 19 men and 1 woman. Median operative time was 448 minutes. Median blood loss was 175 cm 3 . Median intensive care unit stay was 4 days, and median total hospital stay was 9 days. Overall anastomotic leak rate was 20%. Five patients developed an anastomotic stricture, all successfully managed with endoscopic dilation. There were 2 recurrent laryngeal nerve injuries, which resolved. There was no intraoperative or 30-day mortality. Between the first 10 consecutive cases and last 10 procedures, the incidence of anastomotic leak and stricture formation decreased from 30% to 10% and 40% to 10%, respectively. During this period, the number of lymph nodes harvested increased 9-fold, and duration of intensive care unit stay decreased from 8.00 to 2.50 days.Conclusions: Laparoscopic inversion esophagectomy is a safe procedure. The learning curve for the inversion approach is approximately 10 operations in the hands of esophageal surgeons with advanced laparoscopic expertise.

Systematic review of minimally invasive resection for gastro-oesophageal cancer

“…Most of these were case series (21 and 14 respectively), the rest consisting of weak case-matched studies (two and six respectively) and three randomized controlled trials 9 -11 . Most studies were single centre (42); three oesophagectomy studies 17,32,40 involved two centres (with one surgical operating team) and there was one multicentre gastrectomy trial 34 . Most were retrospective (16 oesophagectomy and 15 gastrectomy).…”

Is minimally invasive surgery beneficial in the management of esophageal cancer? A meta-analysis

“…The decrease in total morbidity and respiratory complications in the MIE group may be related to the less invasive nature of the operation, which allows improved patient mobilization following MIE, thereby facilitating Meta-analytic research such as in this study has several limitations that must be taken into account when considering its results. First, there are a lot of case series [19][20][21][22][23][24] on minimally invasive approaches to esophagectomy but no randomized controlled trials to compare. However, we should take into account that it is difficult to conduct a prospective randomized study within a reasonable timeframe.…”

Comparison of Laparoscopic Inversion Esophagectomy and Open Transhiatal Esophagectomy for High-Grade Dysplasia and Stage I Esophageal Adenocarcinoma

“…[5][6][7][8][9] Laparoscopic inversion esophagectomy (LIE) simplifies retraction and improves mediastinal visualization during esophageal resection, thus simplifying the operation while maintaining the potential advantages of minimally invasive and 2-cavity approaches. 10,11 The aim of this series was to compare operative outcomes for LIE with those of THE in patients with HGD and clinical stage I esophageal adenocarcinoma.…”

“…10,11 The operation begins with the hiatal dissection and division of the left gastric artery at its base with a vascular stapler. The short gastric vessels are divided and the posterior stomach is mobilized.…”