A new method for intrathoracic anastomosis in laparoscopic esophagectomy

Abstract

The benefits of laparoscopic procedures over the traditional open technique for esophagectomy in the management of esophageal cancer are well documented. A disadvantage of the laparoscopic technique is longer surgery, particularly in the early part of a surgeon's "learning curve." In a two-stage (Ivor-Lewis) procedure, performance of the esophagogastric anastomosis within the chest can be a "rate-limiting step." A circular stapler is used, which requires placement of a purse-string suture or a manually-tied knot around in the transected proximal esophagus to secure the anvil in place. This is technically demanding and time-consuming in the laparoscopic setting. The authors have devised a method that obviates the need for a purse string or knot, simplifying the intrathoracic esophagogastric anastomosis while still achieving a safe anastomosis.

Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers

“…patientsSurgical approachPatients position a Anastomotic techniqueType of anastomosisLayersFixation of anvilWatson et al (1999) [10]2TransthoracicProne positionHandsewnEnd-to-sideSingle layerNACadiere et al (2010) [11]1TransthoracicProne positionHandsewnSide-to-endTwo layersNALee et al (1997) [12]8Transhiatal and transthoracic45° Semilateral positionCircular stapledEnd-to-sideNAPursestringNguyen et al (2001) [15]1TransthoracicLeft lateral decubitus positionCircular stapledEnd-to-sideNAHandsewn pursestringMisawa et al (2005) [17]5TransthoracicLeft lateral decubitus positionCircular stapledEnd-to-sideNAPursestringEndo-stitchBizekis et al (2006) [18]50TransthoracicLeft lateral decubitus positionCircular stapledEnd-to-sideNANRThairu et al (2007) [19]18TransthoracicProne positionCircular stapledEnd-to-sideNALinear staple gun and Z-stitchSutton et al (2002) [21]10TranshiatalSupine position…”

“…To obviate the necessity of the placement of a pursestring suture or a manually tied knot to secure the anvil, Thairu et al [19] described a technique in which the head of the anvil was inserted through the anterior wall of the esophagus, opened with dissecting scissors. A linear staple was fired at 60° to the longitudinal axis first right and after left to the spike of the anvil thus forming a V. Around this aperture a Z-stitch was placed, which secured the anvil in place, followed by an end-to-side anastomosis.…”

Minimally invasive oesophagectomy: current status and future direction

“…Used on soft tissues, this instrument enables the placement of running or interrupted sutures more efficiently by one hand. The alternative Z-stitch technique, [34], utilises cross-firing of a linear stapler to create a 60°angle at the proximal oesophagus whilst the anvil is in situ. The smaller aperture associated with this technique enables a Z-stitch to suffice for anchorage.…”

OrVil™-assisted anastomosis in laparoscopic upper gastrointestinal surgery: friend of the laparoscopic surgeon

“…However, the small number of patients and the short follow-up does not allow the recommendation of this technique. Thairu et al [19] used a linear stapler to close most of the oesophageal circumference around a laparoscopically inserted anvil leaving a small opening which is subsequently closed with a manually placed suture. There were no leaks in 18 patients but no mention of stricture and the median follow-up was not reported [19].…”

“…Thairu et al [19] used a linear stapler to close most of the oesophageal circumference around a laparoscopically inserted anvil leaving a small opening which is subsequently closed with a manually placed suture. There were no leaks in 18 patients but no mention of stricture and the median follow-up was not reported [19]. This technique still requires suturing skills (although it is easier to perform than a full purse-string) and careful orientation of the linear stapler to achieve a satisfactorily snug fit of the anvil.…”