Esophageal Adenocarcinoma Methods and Protocols

41

Fig. 4 The lesser curvature of the stomach is prepared; this point should be

located at least distal to the third branch from the left gastric artery for an ade-

quate lymphadenectomy. It can be more distally located if a narrower gastric

tube is intended

This is the first of a series of stapler used to transect the stomach

to make a narrow gastric conduit. The application of one stapler

at this stage of the operation will make the subsequent use of

further staplers during the thoracic phase easier (see Note 2).

●● A Heineke-Mikulicz pyloroplasty is then performed although

some surgeons would forgo his step (Fig. 5 ) (see Note 3). A

Kocher maneuvre is not mandatory provided the stomach is of

sufficient length. However, this maneuvre is easily performed

and does have the advantage of straightening the “axis” of the

pyloroduodenal region when the stomach is brought up to the

right thoracic cavity. After careful hemostasis, the abdomen is

closed. Abdominal drains are not required.

Steps of operation:

●● A posterolateral thoracotomy through the fifth intercostal

space is usually performed. Alternatively, an anterolateral tho-

racotomy can also be done with sparing of the latissimus dorsi.

A controlled fracture of the sixth rib posteriorly eases distrac-

tion of the rib space. Two rib spreaders placed at right angles

to each other are used to open up the rib space (Fig. 6 ).

3.3 Operating
Technique: Thoracic
Phase

Surgery for Esophageal Adenocarcinoma