Esophageal Adenocarcinoma Methods and Protocols

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Steps of operation:

●● A midline or a bilateral subcostal incision is made. The author

prefers the latter because it gives improved exposure to the

upper abdomen, especially in obese patients.

●● The stomach is mobilized. The gastrocolic omentum is taken

off the greater curvature of the stomach preserving the right

gastroepiploic vessels and arcades (Fig. 1 ). Complete omentum

resection is not necessary. The left crus is exposed when the

short gastric vessels are divided and the fundus mobilized medi-

ally. The phrenoesophageal membrane is detached and the

abdominal esophagus and cardia can be freed on the left side.

●● The gastrohepatic ligament is then detached from the liver and

from the portal structures. The anterior vagus nerve can be

divided at this point. The esophagus is thus freed on both sides

as well as anteriorly (Fig. 2 ). A sling placed around the lower

esophagus, such as a Penrose or latex drain, may help later dis-

section by providing retraction.

●● The stomach is then reflected upwards and dissection is begun

at the celiac trifurcation. Using fine electrocautery, dissection is

performed along the anterior aspect of the common hepatic

artery. Lymphadenectomy can then proceed laterally toward the

hepatoduodenal ligament (Fig. 3 ). It is sufficient to remove

nodes along the anterior surface of the common hepatic artery.

Medially toward the origin of the left gastric artery at the celiac

3.2 Operating
Technique:
Abdominal Phase

Fig. 1 Picture showing the gastrocolic ligament being divided. The right gastro-

epiploic vessels must be carefully preserved as this is the only reliable blood

supply to the stomach tube

Surgery for Esophageal Adenocarcinoma