# Minimally Invasive endoscopic 3-field Esophagectomy with Jejunostomy Tube



## Tonyea (Jul 17, 2012)

Has anyone come across one of these.  This is the first one of this type of Surgery we have seen here and we are having a real hard type finding any codes for this.  Any help would be greatly appreciated!  Thanks


Attending Surgeon: 1
Assistant Attending: 1 
Resident Surgeon: 1

Procedure(s): Minimally Invasive endoscopic 3-field Esophagectomy with Jejunostomy Tube 
Placement

Specimen(s): Esophagus and proximal stomach. Three additional distal margins, 
marked with sutures.

Drain(s): 
1. Left neck 13 French round drain
2. Right 28 French chest thoracostomy tube
3. Jejunostomy feeding tube

Complications: None apparent

Findings:Large bulky tumor at the GEJ extending onto the gastric cardia; no 
evidence of metastatic disease in the abdomen or right chest; Frozen sections of 
distal margin negative for disease.

Statement of Medical Necessity: 
Pt is a XX year old man with cT3N1M0 stage IIIb esophageal 
adenocarcinoma. He also has a history of anemia, HTN, DVT (UE/LE). He was 
preadmittd day prior to surgery for placement of IVC filter. No interval events 
overnight. We plan to perform a three field minimally invasive esophagectomy as 
well as a feeding jejunostomy.
All material risks, benefits, and alternatives were discussed with the 
patient/family, who understood and were agreeable to intervention. Informed 
consent was obtained.

Description of procedure: 
The patient was brought to the operating room and placed on the operating table 
in supine position. General endotracheal anesthesia was obtained with a double 
lumen ETT. Foley catheter was placed. The hair on the abdomen, chest, and neck 
was clipped. The patient was positioned in the left lateral decubitus position. 
All pressure points were identified and padded. A 5mm port was placed around the 
eighth intercostal space in the mid-axillary line. This was used to insufflate 
the chest. The lung was dessuflated, and patient was on single lung ventilation 
for this portion of the case. The chest was insufflated to a pressure of 10mmHg. 
This port was subsequently upsized to a 12mm port. Additional 12mm working port 
was placed in the seventh intercostal space in the anterior axillary line. In 
addition to this, three more 5mm working ports were placed in the posterior 
axillary line and in the anterior axillary line. All ports were placed under 
direct visualization. The inferior pulmonary ligament was identified and divided 
with electrocautery. The mediastinal pleura was opened to expose the esophagus. 
The azygous vein was identified at its entry point into the superior vena cava. 
A 60mm vascular stapler was fired across the azygous vein at this location. The 
esophagus with its surrounding fat and lymph nodes was dissected, and a Penrose 
drain was placed around it to facilitate exposure. The mediastinal pleural was 
dissected, freeing up the esophagus in its entire thoracic course. Once the 
esophagus was mobilized, a 28 French chest tube was placed through the camera 
port and secured into place with 2-0 ethilon suture. All other ports were 
sutured closed with 4-0 monocryl and dressed with dermabond. The patient was 
turned to supine position, then repositioned with legs split. All pressure 
points were identified and padded.

The abdomen, chest, and neck were prepped and draped in the standard sterile 
fashion. 
Supraumbilical incision was made with an 11 blade. Either side of the incision 
was grasped with a towel clamp, and a Veress needle was inserted into the 
abdomen. Intraperitoneal location was confirmed with the saline drop test. The 
abdomen was then insufflated, with a low opening pressure, flow was increased 
until the pressure measured 15mmHg. 

A 12mm trocar was placed through the supraumbilical site. A 12mm 30 degree 
laparoscope was inserted, and the abdomen was inspected. There were no 
identifiable injuries from initial trocar placement.  Additional trocars were 
inserted: these included a 12mm left upper quadrant port in the mid-clavicular 
line just below the costal margin, a 5mm port in the left lateral abdomen at the 
costal margin at the anterior axillary line, and a 5mm port in the right upper 
quadrant in the mid-clavicular line, just below the costal margin. An additional 
15mm port was placed in the right mid-abdomen.  All ports 
were placed under direct visualization without injury. 

Attention was first directed at performing the jejunostomy. The omentum was 
gently lifted up off small bowel, and the proximal small bowel was traced back 
to the ligament of Treitz. From there, the jejunum was passed until we reached 
approximately 30cm from the LT. This was the point chosen for the jejunostomy. A 
spot was chosen on the left mid-abdomen just lateral and slightly superior to 
the umbilicus. A diamond was drawn out and these were the locations chosen for 
insertion of T fasteners. T fasteners were placed into the abdomen under direct 
visualization, then inserted into the jejunum. Intraluminal position was 
confirmed by instilling air into the jejunum. This was performed four times. An 
18 gauge needle was inserted in the middle of the T fasteners, and a guide wire 
was inserted into the jejunum and directed distally under laparoscopic 
visualization. The tract was dilated, and a peel-away sheath was inserted into 
the jejunum. The feeding tube was inserted and similarly directed distally. The 
sheath was removed. The T fasteners were tightened, and the phalange on the J 
tube was sutured to the skin with 2-0 ethilon suture.

A Nathanson liver retractor was placed under direct visualization through a port 
site in the midline. The left lobe of the liver was carefully retracted to 
expose the hiatus.The patient was placed in steep reverse Trendelenburg 
position. 
Atraumatic laparoscopic graspers were used to mobilize the stomach and retract 
it inferiorly and toward the left lower quadrant. The right crus was identified 
and cleared of investing tissue. The dissection was carried over the arch of the 
crura. The phrenoesophageal ligament was divided.  The lesser omentum was opened 
with ligasure device. The incision was extended over the hiatus to the left 
crus. The short gastric vessels were divided with ligasure. The posterior aspect 
of the stomach was retracted toward the right lower quadrant, exposing the left 
crus, which was further cleared of its investing tissue. Once the esophagus was 
fully isolated and mobilized, it was encircled with a penrose drain, which was 
temporarily sutured together with an 0 PDS endoloop suture. This penrose drain 
was subsequently used to retract the esophagus in an atraumatic fashion during 
the remainder of the procedure. 

The omentum was taken down off the stomach with laparoscopic ligasure, taking 
care to preserve the right gastroepiploic arcade. The omentum and gastrocolic 
ligament was divided. Once the stomach was fully mobilized on its greater 
curvature, attention was directed at mobilizing the lesser curvature. This was 
done in a similar fashion until the left gastric vessel was identified. This was 
divided with a laparoscopic vascular stapler. The duodenum was mobilized via a 
Kocher maneuver. Once the stomach was fully mobilized, we constructed the 
gastric tube that would become the neoesophagus. Prior to performing this, we 
asked our anesthesia colleagues to pull back the nasogastric tube as to avoid 
incorporating it into the suture line. A green load sealing endo-GIA stapler was 
used to serially divide the stomach, starting on the lesser curvature, 
preserving the right gastric artery. The stapler was repeatedly fired around the 
stomach, following the curve of the greater curvature, creating a new tube that 
measured approximately 3cm in diameter. We took additional distal margins that 
were sent to pathology. Hemostasis was verified. Once the majority of the 
dissection was completed, the hiatal dissection was extended into the 
mediastinum and the right chest, connecting the two (laparoscopic and 
thoracoscopic) operative planes. In order to facilitate passage of the mass 
through the hiatus, the crura were divided with ligasure 1cm on each side. The 
gastric tube was then intracorporally sutured with two 0 ethibond sutures to the 
distal end of the esophagus/proximal stomach. Attention was then directed into 
the neck. 

A left neck incision was made along the anterior border of the 
sternocleidomastoid muscle. The incision was deepened through the subcutaneous 
tissues with electrocautery. The platysma was divided. The sternocleidomastoid 
muscle was dissected free of its medial soft tissue attachments and retracted 
laterally. The nasogastric tube within the esophagus was palpated, and this 
guided our dissection. The left lobe of the thyroid was encountered. This was 
retracted medially. The trachea was palpated along with the esophagus with the 
NGT in place. In this tracheoesophageal groove, we positively identified the 
left recurrent laryngeal nerve. This was perserved free of injury, although 
there may have been some stretch on the nerve due to gentle retraction. Once the 
esophagus was identified, it was bluntly cleared of its surrounding attachments. 
A penrose drain was placed around the esophagus. Digital blunt dissection was 
performed in the base of the neck / thoracic inlet to free the esophagus of its 
surrounding attachments. Once this was performed. The laparoscope was re-
inserted into the abdomen. From the neck, the esophagus was delivered into the 
wound. From the abdomen, the gastric tube / neoesophagus was visualized passing 
through the hiatus without twisting. Once in the wound, the eosphagus was marked 
on its anterior aspect with a silk suture. The NGT was pulled back. The 
esophagus clamped then divided with heavy scissors within its proximal location 
in the neck. The esophagogastric specimen was removed from the field. The NGT 
was delivered through the esophagus and retracted back. An anastomosis was 
performed between the esophagus and the tubular stomach. This was a two layered, 
(3-0 silk muscular and 3-0 PDS full thickness) hand sewn anastomosis. Prior to 
completing the anastomosis, the NGT was passed back into the neo-esophagus and 
directed down to the hiatus. The NGT was visualized laparoscopically to be at 
the hiatus. Of note, the pylorus of the stomach was noted to be located just 
below the hiatus. The neck wound was irrigated with normal saline, and hemoastis 
was checked. A 13 French round drain was placed at the site of the anastomosis. 
The platysma was closed over this wound with 3-0 vicryl. The incision was closed 
with deep dermal 3-0 vicryl and skin layer 4-0 monocryl. Once intraabdominal 
hemostasis was verified, the laparoscopic ports were removed under direct 
visualization. The 15mm port fascia was closed with 0 vicryl. All port sites 
were closed with 4-0 monocryl. All incisions were dressed with dermabond. Of 
note prior to all incisions, local anesthetic was infiltrated. The patient was 
awakened from anesthesia, extubated, and transported to SICU in fair condition.

Counts: All sponge, instrument, and needle counts were reported to be correct at 
the conclusion of the case.

Disposition: SICU in fair condition.

Postoperative Plan: 
-Strict NPO
-NGT secured, to not be used or manipulated, to be kept on low continuous wall 
suction
-Chest tube to -20cm H20 suction
-Lifelong PPI
-Start heparin gtt for history of DVT on postoperative day 1 if no signs of 
postoperative bleeding


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