Thoracic

Question 1

Transhiatal Esophagectomy (THE) Steps: (AKA cervical esophagogastric anastomosis)

Answer 1

1. Upper midline laparotomy
2. Divide triangular ligament, liver to the right
3. Divide and ligate high short gastric, left gastroepiploic, and left gastric vessels. (Preserve right gastric, right gastroepiploic
4. Generous Kocher maneuver
5. Extramucosal pyloromyotomy
6. Mobilize distal 10cm of esophagus under direct vision
7. Left cervical incision, anterior to SCM, mobilize cervical esophagus, Mobilize thoracic esophagus
8. Divide esophagus in neck
9. Divide stomach 4-6cm from EGJ, progressively straightening stomach
10. Transpose stomach to cervical wound
11. Loosely narrow diaphragmatic hiatus, suture stomach to edge of diaphragm
12. Jejunostomy: 14Fr rubber jejunostomy feeding tube.
13. Anastamosis.

Question 2

Ivor Lewis Esophagectomy Steps:

Answer 2

1. Lymphadenectomy of celiac trunk, division of left gastric pedicle. ligate left gastric.
2. Mobilization of the greater curvature.
3. Transhiatal dissection to level of inferior pulmonary vein
4. Creation of conduit
5. Feeding tube jejunostomy
6. Left thoracoscopy: Open anterior and posterior pleura, divide azygous vein
7. Circumferentially mobilize esophagus to just above azygous, identify airways, divide esophagus
8. Gastric conduit pullup, path assesment of margin, Mediastinal lymphadenectomy
9. OrVil passed to proximal staple lilne, anvil in distal, assess conduit perfusion
10. Anastamosis