ESOPHAGUS > Thoraco-Laparoscopic Ivor-Lewis Esophagectomy

Abdominal Part
Patient and Port position: Patient placed in modified Lloyd davies position. 
Pneumoperitoneum created by veress needle through 10 mm Supraumbilical skin incision which later on converted into 10mm camera port.  Right MCL 12mm, left MCL-10mm, RUQ-5mm, epigastric 5mm and left arterior axillary 5mm ports. 

STEPS:  Initial step is to visualize all quadrants of peritoneal cavity, liver surfaces, primary tumor location for metastasis, lymphadenopathy and ascites.  
GE junction tumor dissected from upper pole of Spleen, Splenic hilum and left crus of diaphragm.  Greater omentum divided beyond gastric arcade. Lesser omentum divided.  Left gastric vessels dissected clipped at their origins and divided with dissection of celiac lymphnodes. Tumor along with lower esophagus dissected from right crus of diaphragm. Gastric tube made by sequential firing of staples (endo GIA stapler blue) from Crow’s foot to just below fundus 10cm away from tumor.  Feeding Jejunostomy done 20cm distal to DJ flexure done using 14 F Foley’s catheter. 

Thoracic part :
Patient and Port position: Patient placed in prone position. 
Optical trocar 10mm introduced just below tip of right scapula. 5mm port in 7thIC space in posterior axillary line, 5mm port in 5th IC space just lateral to paraspinal muscles. 5mm port in 7th IC space just lateral to paraspinal muscles. 
Azygous vein dissected, clipped with LT 300 and divided.  Esophagus dissected from surrounding vitals structures along with paraesophageal and subcarinal lymphnodes after dividing inferior pulmonary ligament.  Thoracic esophagus divided at the level of azygus vein.  Gastric tube along with tumor pulled up in thoracic cavity and specimen divided from gastric tube.  Esophagogastric anastomosis done by single layer continuous 2-0 PDS sutures.  5cm incision given in 7th IC space anterolaterally and specimen retrieved outside.