Minimally Invasive Esophagectomy

Over the past decade, minimally invasive esophagectomy (MIE) has become an accepted approach to treating cancers of the esophagus. When performed at high-volume centers, MIE has been shown to carry similar morbidity, mortality, and oncologic outcomes as open esophagectomy, with the advantages inherent to minimally invasive surgery. MIE techniques have evolved significantly from the initial hybrid approaches of thoracoscopy combined with laparotomy1, 2, 3, 4 to the current MIE, which is performed entirely using laparoscopy and thoracoscopy. Although technically demanding and associated with a significant operator learning curve, MIE is an excellent option for esophageal resection. Advantages include less blood loss, decreased incidence of respiratory complications, shorter of hospital stay, and reduced narcotic requirements.5, 6, 7, 8, 9 In the authors’ experience, MIE is also associated with less postoperative pain.

At present, minimally invasive approaches for esophagectomy include laparoscopic transhiatal, laparoscopic-thoracoscopic 3-hole (McKeown), and laparoscopic-thoracoscopic Ivor Lewis esophagectomy. Each of these approaches can be performed with either a lymph node sampling technique or a more complete lymph node dissection. The choice between MIE approaches is, to a large degree, based on surgeon preference. However, the operative approach is at times dictated by the anatomic location of tumor and the margins required for an R0 resection. The choice of operative approach also directly affects postoperative morbidity. Specifically, approaches that include a cervical anastomosis have a higher incidence of anastomotic leak, stricture, recurrent laryngeal nerve injury, and pharyngoesophageal swallowing dysfunction.10, 11, 12 In comparison, transthoracic approaches have a higher incidence of cardiopulmonary complications and more morbid consequences when an anastomotic leak occurs.¹³

The number of lymph nodes sampled at operation has important prognostic and treatment implications. It is also clear that to obtain a more aggressive resection with complete 2-field lymph node dissection, the operation must include thoracic exposure via an Ivor Lewis or McKeown modification.14, 15, 16, 17 A trend toward improved 5-year survival has been observed in subsets of patients with more locally advanced cancers treated with an Ivor Lewis approach.13, 18, 19 In addition, local recurrence rates of less than 10% have been reported after complete lymph node dissection using a thoracic approach, compared with local recurrence rates of greater than 40% with transhiatal operations.20, 21, 22 Despite these data, randomized trials comparing transhiatal and transthoracic esophageal resection have not shown significant survival differences between the 2 approaches. However, a trend toward improved long-term survival has been shown after transthoracic resection.13, 19

The authors previously reported their extensive experience with MIE using a modified McKeown (3-hole) technique.23, 24 These articles demonstrated that MIE could be performed safely with stage-specific survival that was equivalent to previously published open series.25, 26 In light of concerns regarding cervical dissection and anastomosis, the authors' preferred approach is now a completely laparoscopic-thoracoscopic (Ivor Lewis) esophagectomy with abdominal (celiac, left gastric, splenic) and mediastinal (paraesophageal and subcarinal) lymphadenectomy.27, 28 The minimally invasive Ivor Lewis approach works well for most distal esophageal cancers, gastroesophageal junction tumors with gastric cardia extension, and short- to moderate-length Barrett esophagus with high-grade dysplasia. In addition, when there is concern for the length of the gastric conduit, an intrathoracic anastomosis is preferable. In cases of primary gastric tumors with significant lesser curve extension that involve the incisura, the authors prefer a total gastrectomy with roux-en-Y reconstruction. Total laparoscopic and thoracoscopic Ivor Lewis resections should not be performed for upper third or mid-esophageal cancers with significant proximal extension, because of the concern for adequate margin of resection. In this article, the authors describe their current operative technique and present the results and insights that have been attained using this approach.