clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

The alternative technique for anastomosis after colonic interposition is a laterolateral colo-esophageal anastomosis performed by a linear stapler.

Combined Transhiatal Transthoracic Esophagectomy

Introduction

We reported this technique for the first time in 1980. It uses the concepts acquired in transhiatal dissection in tumors located more superiorly in the cervicothoracic esophagus or in the middle third of the thoracic esophagus, and avoids a “blunt” dissection performed without visual control, which increases the possibility of iatrogenic injury to mediastinal structures. However, at present more and more surgeons favor transhiatal esophagectomy for its technical simplicity and favorable outcome.

210 SECTION 2 Esophagus, Stomach and Duodenum

Standard Postoperative Investigations

See chapter on “Subtotal Esophagectomy: Transhiatal Approach.”

Postoperative Complications

Early Postoperative Course

■Pulmonal infections

■Septic complications: subphrenic or intra-abdominal abscess; cervical wound infection

■Anastomotic leak

■Necrosis of the interposition

■Enterothorax

Late Postoperative Course

■Cicatricial strictures of the cervical esophagoor pharyngeo-colostomy, mostly due to anastomotic leak

■Kinking of the interposition

■Mechanical trauma to a subcutaneous graft, which often needs surgical intervention

■Propulsive disorder

Tricks of the Senior Surgeon

■Treatment of the stenosis is performed by bougienage or balloon dilatation. Very rarely is surgical intervention indicated.

■Reasons for necrosis of the interposition are: decrease of circulation due to kinking or compression of the main vessels, hypovolemia, and hypercoagulability. Avoidance is by interposition of a long colonic segment without tension. Optimization of the postoperative hemodynamic and rheologic parameters is necessary.

■Kinking of the interposition is a rare but dangerous complication, which often requires surgical intervention, due to clinical symptomatic disturbance of the gastrointestinal passage by elongation of the interposition. Surgical intervention is performed by shortening of the graft.

■To avoid enterothorax phrenicotomy has to be performed.

Laparoscopic Gastrectomy

Geert Kazemier, Johan F. Lange

Introduction

Laparoscopic resection of the stomach should mimic an open operation as closely as possible. This is applicable to the technique, as well as to the considerations on which the indication is based. Palliative resection for gastric malignancy can be indicated to prevent hemorrhage or obstruction.

Indications and Contraindications

Preoperative Investigation/Preparation for the Procedure

See chapter “Total Gastrectomy with Conventional Lymphadenectomy.”

Instrumentation

■Two monitors

■Three 10to 12-mm trocars, two 5-mm trocars

■One 15-mm trocar (optional) to pass the 60-mm stapler and retrieval bag

■30° laparoscope

■Unipolar or bipolar coagulation

■Hemostatic device (LigaSure, Ultracision)

■Standard laparoscopic instruments for advanced laparoscopic surgery, including fenestrated clamps and endo-Babcock clamp

■Vascular clip applier

■Endostapler (45–60mm, with white, blue and green cartridges)

■Liver retractor

■Vessel loops

■Gastroscope (optional, to identify small lesions)

■Retrieval bag