ESOPHAGUS  > Thoraco-Laparoscopic Mckeown's Esophagectomy

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. 

STEPS : Initial step is thorough visualization of right pleural cavity for primary tumor, metastasis, pleural effusion, paraesophageal and subcarinal lymphnodes.

Azygus 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 from thoracic inlet to esophageal hiatus. Thoracic duct dissected along with esophagus, clipped at esophageal hiatus and divided.

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 was later on converted into 10mm camera port.  Right MCL 12mm, left MCL-10mm, RUQ-5mm, epigastric 5mm and left anterior axillary 5mm ports made. 

STEPS:  Initial step is to visualize all quadrants of peritoneal cavity, liver surfaces for metastasis, lymphadenopathy and ascites.  
Greater omentum divided beyond gastric arcade from pylorus to angle of His. Lesser omentum divided.  Left gastric vessels dissected clipped at their origins and divided with dissection of celiac lymphnodes. Gastric tube made by sequential firing of staples (endo GIA stapler blue) from Crow’s foot to just below fundus.  Feeding Jejunostomy done 20cm distal to DJ flexure done using 14 F Foley’s catheter.

Neck Part :
Patient position: Supine position with extended neck and head turned toward right.
Transverse incision given. 2 heads of Sternocleidomastoid muscle separated. Middle thyroid vein ligated and divided. Cervical esophagus dissected circumferentially and gastric tube along with specimen pulled into the neck. Proximal division of esophagus done 5cm below upper esophageal junction. Esophago gastric anastomosis done by 3-0 interrupted silk sutures.