Objective To explore the clinical experience of thoracoscopic combined with laparoscopic esophagectomy for esophageal cancer. Methods From November 2008 to September 2009, we treated 40 patients with esophageal cancer by thoracoscopic combined with laparoscopic esophagectomy. 30 males and 10 females, aged 52-78 years, were treated with thoracoscopic combined with laparoscopic esophagectomy. The average age was 65 years. The lesion sites were: upper esophageal cancer in 2 cases, middle esophageal cancer in 32 cases, and lower esophageal cancer in 6 cases. 39 cases were squamous cancer and 1 case was adenocarcinoma. The surgical method was to free the esophagus and remove the lymph nodes under thoracoscopy, free the stomach under laparoscopy, and perform an esophagogastric anastomosis through the posterior sternal tunnel and up to the neck. As a result, from November 2008 to September 2009, we resected 40 cases of esophageal cancer with this new model.
Three cases were due to thoracic adhesions, one case was due to obvious invasion of the tumor and the thorax was transferred to assist small incision, and the abdomen was not transferred to open abdomen. The operative time of the whole group was 240-320 min, average 270 min, thoracoscopic time 45-90 min, average 60 min, laparoscopic time 45-90 min, average 60 min. Intraoperative bleeding was 150 ml-300 ml, average 200 ml. 8-20 lymph nodes were removed, average 11.8. The postoperative hospital stay was 10-13 days, with an average of 11 days. There were no intraoperative bleeding complications.
Postoperative complications: 6 cases of cervical anastomotic fistula (postoperative day 8-14) were healed by wound dressing change; there were no celiac disease, pulmonary infection, or pulmonary insufficiency after surgery. Conclusion Thoraco-laparoscopic esophageal cancer resection according to this design minimizes trauma and complications, and there is no significant difference between tumor resection and lymph node dissection and other surgical methods, and the operation is more simple and easy to perform and can be easily promoted.
As China is the country with the highest incidence and mortality rate of esophageal cancer in the world, surgical resection is one of the main methods to treat esophageal cancer, but traditional open esophageal cancer resection is highly traumatic and has many postoperative complications. At the end of last century, minimally invasive techniques were emphasized by all fields of surgery, and lumpectomy techniques were widely used. At present, most doctors in China still adopt the thoracoscopic + open approach to complete esophagectomy for esophageal cancer.
In clinical practice, thoraco-laparoscopic esophageal cancer resection is a type of lumpectomy that is very difficult and less invasive at present, and because it requires both thoracoscopic and laparoscopic techniques, few units in China perform it, and the modes vary. In our practice, we summarized the domestic and foreign experiences, based on the limited operation angle of lumpectomy and the anatomical characteristics of esophagus and stomach, we got rid of the constraints of traditional open surgery resection steps, and improved the incision and operation flow of thoraco-laparoscopic esophageal cancer resection, and completed 40 cases of thoraco-laparoscopic esophageal cancer resection using this mode, which are reported as follows.
1. Clinical data and methods.
1.1 General information
Forty patients, 30 males and 10 females, aged 52-78 years old, were patients with esophageal cancer in this treatment group. The average age was 65 years. All patients underwent preoperative gastroscopy and were pathologically confirmed as esophageal squamous carcinoma and adenocarcinoma, and CT indicated that they were all patients with esophageal cancer that could be resected and lymph node dissection. Lesion sites: 2 cases of upper esophageal cancer, 32 cases of middle esophageal cancer, 6 cases of lower esophageal cancer, 39 cases of squamous cancer and 1 case of adenocarcinoma.
1.2 Surgical methods
1.2.1 Anesthesia
Double-lumen tracheal intubation, intravenous compound anesthesia, and healthy side lung ventilation. The gastric contents were emptied by suctioning the gastric tube as much as possible before surgery.
1.2.2 Thoracoscopic surgery
The patient was placed in a 90-degree left lateral recumbent position with the upper limb of the affected side raised forward and fixed on a brace, and the operator was located on the dorsal side of the patient, and the thoracoscopic hole was selected at the 7th intercostal space in the mid-axillary line, about 1.0-1.5 cm long. A pulmonary retractor was placed in the suboperating hole, and the lung was pressed ventrally to expose the esophagus as far as possible along the esophageal pathway, and the thoracic cavity was probed for implantation metastases, and the mediastinal pleura was dissected longitudinally along the esophagus with an ultrasonic knife (or electrocoagulation hook) to investigate whether there was significant esophageal invasion. The odd vein was freed, and the ends were clamped and severed with a biological ligature buckle.
Band traction esophagus and free the esophagus with ultrasonic knife starting at the normal esophagus below the tumor, up to the thoracic inlet and down to the diaphragmatic esophageal fissure. Regress the gastric tube, dissect the esophagus below the tumor, resect the esophageal cancer, and clear the lymph nodes in the inferior parapulmonary vein, inferior ramus, esophageal bed, and upper mediastinum. Thoroughly stop the bleeding, flush the chest cavity, check the bronchial membrane and other places for air leakage, place a chest drain in the observation hole, close the incision and restore ventilation of both lungs.
1.2.3 Laparoscopic surgery
The patient was placed in a lying position, with the head high and feet low, and an incision of about 1 cm in length was made near the top of the umbilicus, and the skin and subcutaneous tissues were incised, and a pneumoperitoneum needle was placed to establish an artificial pneumoperitoneum. In this position, a 12 mm trocar is placed and the scope is inserted. 2 main operating holes, one located at the midclavicular line and 3 cm above the umbilicus, a 12 mm trocar is placed, one located at the anterior axillary line and 5 cm above the umbilicus, a 5 mm trocar is placed, and one secondary operating hole, located under the glabella, a 12 mm trocar is placed. the operator is positioned on the right side of the patient and the abdominal cavity is explored: the abdominal cavity is examined for adhesions, and the liver, spleen, pelvis, and greater omentum for nodules and masses. The patient is tilted to the right side at 30°, and the gastric greater curvature is freed from the bottom to the top with an ultrasonic knife, noting the vascular arch of the right gastroretinal membrane, up to the diaphragmatic esophageal fissure, and severing the left gastroretinal artery and the short gastric artery, and the peritoneum around the ventral segment of the esophagus.
The patient was tilted 30° to the left side, the left lobe of the liver was retracted, the lesser omentum was incised with an ultrasonic knife, the hepatogastric ligament and peritoneum of the ventral segment of the esophagus were freed, and the diaphragmatic esophageal fissure was superiorly reached, the left gastric vessels were tractored free at the superior margin of the pancreas, and the ends were clamped with a bioligation clasp, disconnected, and the left gastric artery, splenic artery, and parietal lymph nodes of the common hepatic artery were removed. The septal pedicles on both sides were exposed and the ventral segment of the esophagus was tractored to the abdominal cavity. The pneumoperitoneum was abolished, the subxiphoid incision was enlarged by about 3 cm, the stomach was tractored to the outside of the body, and the cardia was closed by a linear cutting suture on the lateral side of the gastric lesser curvature,, which was cut off to make it a partially tubular stomach, and the cut edge was closed by an interrupted pulpy muscle layer. The highest point of the gastric fundus is marked with a 7-gauge silk suture, and the stomach is returned to the abdominal cavity without torsion, with the silk left outside the body.
1.2.4 Neck surgery
A 4-cm incision was made through the anterior border of the left sternocervical papillary muscle, the cervical segment of the esophagus was freed along the medial side of the cervical vascular sheath, the esophagus was hooked up, the esophagus was disconnected at the neck, a posterior sternal tunnel was made, the stomach was retracted to the neck through this, the posterior wall of the anastomosis was treated with a linear cutting closure, the gastric tube was placed to the pylorus, the anterior wall of the anastomosis was closed with continuous sutures, complete hemostasis was achieved, and the incision was closed.
2. Results
From November 2008 to September 2009, we resected 40 cases of esophageal cancer with this new model. There was no perioperative death in the whole group, 3 cases were due to thoracic adhesions, 1 case was due to obvious tumor invasion and the thorax was turned to assist small incision, and no abdomen was turned to open the abdomen. The operating time of the whole group was 240-320 min, average 270 min, thoracoscopic time 45-90 min, average 60 min, laparoscopic time 45-90 min, average 60 min. Intraoperative bleeding was 150 ml-300 ml, average 200 ml. 8-20 lymph nodes were removed, average 11.8. The postoperative hospital stay was 10-13 days, with an average of 11 days. The chest drain was removed 5-7 days after surgery, and the total chest drainage was 560-1210 ml, averaging 820 ml. postoperative total parenteral nutrition.
The postoperative gastric fluid volume was low, about 100-400 ml, average 250 ml. Gastrointestinal decompression was stopped from the 2nd day onwards (except for pleural rupture), and fluid was introduced after 7 days, and soft food was introduced on the next day. 12-14 days were discharged from the hospital, average 13 days. There were no intraoperative bleeding complications. Postoperative complications: 6 cases of cervical anastomotic fistula (postoperative day 8-14) were healed by wound dressing; there were no celiac disease, pulmonary infection, or pulmonary insufficiency after surgery. Postoperative pathological stage: 1 case of stage I, 34 cases of stage II, and 5 cases of stage III. The patients were regularly reviewed or followed up by telephone after discharge. Thirty-nine patients were followed up and one case was lost. The follow-up period was 3-12 months, with an average of 7.3 months. There were no recurrence, metastasis, or death in all cases. There was no difficulty in swallowing or eating in the follow-up patients.
3. Discussion
3.1 Incision design
We made changes to the thoracic and abdominal surgical incisions compared with and other operators’ incisions. This model minimizes the role of the assistant, and any surgeon without experience in this surgery can help the main surgeon to complete this surgery.
3.1.1 Thoracoscopic surgery
Compared with the chest incision of other operators, we have the observation holes anteriorly in order to facilitate the operation. There are two main operating holes, one is located in the 8th intercostal space behind the posterior axillary line, and this hole is moved forward and down, almost in a parallel line with the esophagus, from which the ultrasonic knife ligature clip is inserted at an angle of 30° with the odd vein and esophagus and almost in the same plane with the diaphragmatic fissure, so it is very convenient to place the ligature clip to disconnect the odd vein and free the esophagus. The other posterior axillary line is posterior to the 5th intercostal space, and this hole is moved forward and upward, and after extending the grasping clamp, it is almost in the same plane with the odd vein and any part of the chest cavity can be reached comfortably, which is convenient for the main surgeon’s left hand to assist in handling the odd vein and freeing the esophagus.
3.1.2 Laparoscopic surgery
Compared with the abdominal incision of other operators, we have also modified the abdominal incision. Due to the influence of the general surgeon operating the laparoscope, the four operating holes of other operators are distributed in a “V” shape. We saved about 2 incisions and moved one of the operative holes to the subxiphoid process, which also provides good traction on the liver and helps to expose the lateral gastric cavity.
3.2 Operating procedure
In this model, our experience proves that ultrasonic knife freeing the esophagus and stomach is quite safe and without bleeding complications, except for the odd vein and left gastric artery which require special treatment. The abdominal surgical position is in the horizontal position, which saves the operative time.
3.3 Postoperative complications
Compared with the traditional open surgery and thoracoscopic + open way to complete esophageal cancer resection, this mode minimizes trauma and complications, and there is no significant difference between tumor resection and lymph node dissection and other surgical methods. It was observed through this group of cases that the postoperative chest drainage and gastric fluid drainage were significantly less than those of traditional surgery, and there were no pulmonary complications, celiac disease, or gastric emptying disorders.
With further increase in surgical volume and experience, the gastric tube may be withdrawn on the first postoperative day. However, similar to foreign reports, we had a higher incidence of initial cervical anastomotic fistula, which we speculate may be related to chronic ischemia of the stomach. To reduce the incidence of cervical anastomotic fistula in the posterior sternal tunnel, we believe it is important to unblock the sternal outlet and reduce the compression of the stomach by the sternal outlet. So later we paid attention to the sparing of the sternal outlet and the incidence of cervical anastomotic fistula decreased.
In conclusion, thoraco-laparoscopic esophagectomy for cancer according to this design is less invasive and safe, and the operation is simpler and easier to promote, but further follow-up is needed.