The patient is placed in a supine position. A laparoscopy is performed by using 5 trocars and a maximum pressure of 15 mm Hg. During laparoscopy, a lymphadenectomy is performed (hepatoduodenal ligament, common hepatic artery, celiac trunk, splenic artery, splenic hilum, paracardial left and right), the greater curvature is mobilized, identifying and sparing the right gastro-epiploic vessels, and a gastric tube (3 cm wide) is created by using a linear stapling device. A jejunostomy catheter is placed approximately 20 cm distal of Treitz ligament, the abdominal phase is terminated, and the incisions are closed (fascia and skin).
Next, the patient is repositioned to a prone position. A thoracoscopy is performed by using 4 trocars and a maximum insufflation pressure of 6–8 mm Hg. The thoracic esophagus is mobilized, and a lymphadenectomy is performed (stations 4, 5, 7, 8, 9, and 10 according to the American Joint Committee on Cancer classification for esophageal cancer). The arch of the azygos vein is divided by using a vascular stapling device. The thoracic duct is transected at the level of the diaphragm and arch of the azygos vein by using 10-mm endoclips and excised with the specimen. The esophagus is divided just cranial to the level of the arch of the azygos vein. The specimen and gastric tube are retrieved in the thorax. A minithoracotomy (5 cm) is performed through which the specimen is resected. An anastomosis is created by using a circular stapling device. The anastomosis may be subsequently sutured with interrupted Vicryl 3.0 sutures. The anastomosis is concealed under the pleura, and an omental wrap is placed around the anastomosis. A nasogastric tube is placed in the gastric tube. After placement of a thoracic drain, the thoracoscopy wounds are closed (muscles and skin).
Next, the patient is repositioned to a prone position. A thoracoscopy is performed by using 4 trocars and a maximum insufflation pressure of 6–8 mm Hg. The thoracic esophagus is mobilized, and a lymphadenectomy is performed (stations 4, 5, 7, 8, 9, and 10 according to the American Joint Committee on Cancer classification for esophageal cancer). The arch of the azygos vein is divided by using a vascular stapling device. The thoracic duct is transected at the level of the diaphragm and arch of the azygos vein by using 10-mm endoclips and excised with the specimen. The esophagus is divided just cranial to the level of the arch of the azygos vein. The specimen and gastric tube are retrieved in the thorax. A minithoracotomy (5 cm) is performed through which the specimen is resected. An anastomosis is created by using a circular stapling device. The anastomosis may be subsequently sutured with interrupted Vicryl 3.0 sutures. The anastomosis is concealed under the pleura, and an omental wrap is placed around the anastomosis. A nasogastric tube is placed in the gastric tube. After placement of a thoracic drain, the thoracoscopy wounds are closed (muscles and skin).
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