44
Further dissection upwards should meet the previously slung
upper esophagus so that the whole intrathoracic esophagus is
freed. The subaortic nodes could be removed at this point just
above the left main bronchus, taking care not to damage the
left recurrent laryngeal nerve medially, and the left pulmonary
artery on the deep limit of dissection (see Note 5).
●● After esophageal mobilization and mediastinal nodal dissec-
tion, the gastric tube is delivered up through the diaphrag-
matic hiatus into the right chest. The gastric conduit can be
tailored by starting transection at a chosen point of the fundus
downwards toward the already fired stapler from the distal
lesser curvature during the abdominal phase of the operation.
Usually, two to three more linear staplers are necessary. A
Satinsky clamp is then applied across the supra-aortic segment
of the esophagus near the apex of the thoracic cavity. The
esophagus is divided distal to the clamp. The esophagus with
the cancer is removed. The gastric tube is placed in the medi-
astinum ready for anastomosis, which is performed either using
a hand- sewn method or stapling (both circular and linear sta-
pling work well, depending on surgeons’ preference) (Fig. 9 )
(see Note 6).
●● After hemostasis, the thoracotomy is closed with a 24Fr chest
drain connected to under-water seal. Alternatively, a simple
closed suction drain can be used without the need for under-Fig. 8 The thoracic duct has been resected; the anal side was ligated on the
surface of the aorta and marked with a metal clipSimon Law