LAPAROSCOPIC ESOPHAGECTOMY

Laparoscopic oesophagectomy:

What is laparoscopic esophagectomy? 

Laparoscopic esophagectomy or Minimally invasive esophagectomy in this procedure diseased portion or cancerous portion of the esophagus removed and stomach is used to reconstruct the esophagus for quicker recovery and decreased pain.first description of minimally esophagectomy in 1992.

Esophagus is the tube like structure that passes food from mouth to throat then stomach.Mostly esophagectomy is done to treat cancer of the esophagus. Some time also be done to treat the esophagus if it is no longer working to move food into the stomach.

Esophageal cancer amongs the cancer with the most rapidly increasing incidence in the western world. Laparoscopic esophagectomy was associated with 77% lower risk of major intraoperative and postoperative complications than open esophagectomy furthermore, laparoscopic esophagectomy was associated with 50% lower risk of major pulmonary complications than open surgery. Overall survival and diseased free survival were atleast as good with minimally invasive surgery or laparoscopic as with the open procedure. 

Causes and symptoms of esophageal cancer:

-Causes of esophageal cancer are smoking and drinking too much alcohol or obesity and too much acidity for long time.

-Cancerous esophagus due to this or adenocarcinoma of the esophagus is related to chronic gastroesophageal reflux disease and symptoms of this disease gerd may also be including heartburn and indigestion 

-Patient come with unexplained weight loss and also esophageal cancer bleed and this cause vomiting of blood or passing of melenia (black tarry stool)

-Painful  esophageal cancer can be feel in the lower chest behind the breastbone or in the upper abdomen. If the cancer has spread there may be pain in other places around the chest or back.

-Patient may experience voice horseness due to vocal cord damage caused by reflux of stomach acid into the throat that caused bad taste in the back of the mouth from reflux.

-As the tumor grows it may cause nerve damage if it inflames the recurrance laryngeal nerve that helps control the vocal cords

-Physical examination may not be helpful in making the diagnosis the esophagus is hidden within the chest cavity and not easily evaluated by physical examination. 

-In the early stage of esophageal cancer there may be no Symptoms at all, It is only when the tumour grows enough to cause problems, do symptoms begins to appear.

-If the cancer has metastasized through the lymph nodes and lymph system, beyond the esophagus, there may be abnormal lymph nodes palpable in the neck below the jaw or above the clavicles. 

Treatment of esophageal cancer is surgery, chemotherapy and radiation theray.

Pre-operative instruction for the patient: 

If patient taking blood thinners like aspirin, plavix, coudamin discuss with surgeon whether patient should continue or stop medication before surgery. 

If patient smoke its stop before the surgery because its increasing the risk of complications. 

Don't eat or drink anything after midnight or night before come to the hospital. 

Leaves valuable or costly items and accessories at home but come with medical insurance card and identity card

Pre surgery patient get epidural pain catheter for helping to reduce pain after the surgery. 

Pre surgery catheterization done for the drainage of urine.

Before the surgery, patient undergo imaging procedure, such as computed tomography (CT) or positron emission tomography - computed tomography (PET/CT) & an assessment of cardiovascular fitness patient also meet with an anestheologists prior to the procedure. The preoperative blood testing is similar before either an minimally invasive esophagectomy or open procedure. 

Laparoscopic esophagectomy done under the full general anesthesia with double lumen flexible endotracheal tube.General anesthesia for pain relief during surgery and comfort to patient.

Fentanyl citrate and muscle relaxtant given to the patient and Endotracheal intubation will given and hypnotic agent like propofol given. 

Than anesthesist continue watching monitor and watch vital signs including pulse, spo2(saturation ), E.C.G,  body temperature and blood until the  patient  will not shifted from operation theatre to general ward

-Inspection of instruments and equipment by surgeon :

Before starting the surgery,  surgeon inspect  all the equipment & instruments  in the operating room and should routinely inspect equipment for any malfunction or servicing needs. Instruments and equipment require 

1. Telescope (laparoscope) 10mm or 5mm (30 degree)

2. Four 10mm trocar and three 5mm       trocar,

3.two 5mm reducer for inserting 5mm laparoscopic instruments through 10mm port

4.endo needle holder

5.Endo curved scissor, straight scissor

6.Hook & unipolar cord, bipolar forcep     or bipolar cord

7.Harmonic and ligasure.

8.laparoscopic myster forcep

9.laparoscopic marinland forcep

10.bowel grassper

11.clip applicator

12.nathanson retractor for liver retraction 

13.extractor forcep 

In this procedure surgeon makes five small incision in the abdomen using the laparoscope attached with video camera for magnification with cold light source for visualization and all this image view on monitor screen then putting the laparoscopic instruments from the laparoscopic ports.

In case of esophageal cancer extensive lymph node dissection is also performed 

The portion of stomach be used to reconstruct esophagus and prepared to move into the chest and replacing the disease portion  of the esophagus then the patient turn then surgeon make four small incision the right side of the chest avoid the spreading ribs esophagus will removed and stomach is turn to the remaining of the stomach and lymph nodes may also be removed that stage.

This procedure completed in three stages:

First stage is video-assisted thoracic surgery (VATS) technique, Esophageal mobilization and lymph node dissection and divide esophagus was performed  in this procedure. The location of the esophageal tumor was confirmed by CT scan, upper gastrointestinal radiography and gastroscope. After esophageal mobilization and paraesophageal  nodes dissection, a chest tube or ICD was placed for drainage of the chest fluid or air.

Second stage of the laparoscopic surgery technique During this stage,laparoscopic hiatal dissection done by surgeon,  the patient was placed  Trendelenburg position, Five trocars were inserted in the abdomen two 10mm port will introduced  than three 5mm port insert i for 5mm laparoscopic instruments and abdomen inflate by CO2 gas for for creating pneumoperitoneum for visualization of organ & tissue and create space for working. After laparoscopic hiatal dissection performed and mobilize the stomach and divide left gastric then mobilize distal esophagus and open right pleura if  lymph nodes is present then also done lymph node dissection that stage.

In the third stage anastomosis done by linear stapler in this procedure deliver stomach than create conduit assess perfusion and place conduit through hiatus.A 3-5-cm incision was made on the left neck and the cervical esophagus was isolated and divided then Anastomosis done.Jejunostomy tube was placed inside the small intestine so that patient can fed while patient are recovering from surgery.

After the surgery patient shifted intensive care unit (ICU) from the operations theatre for close monitoring, respiratory status and vital signs for one day then moved to general floor when patient stable usually after 24 hours after surgery , hospital stay of about one week (7days) but at home recovery of four to six weeks benefits of laparoscopic or minimally invasive surgery is decreased length of hospital stay and dimnish pain and deceased respiratory complications.

Urinary catheter remove approximately two days after surgery if patient have prostate or urinary retention problem then tell to doctor. 

Pain management done by after the surgery by epidural catheter place inside the spine or delivering pain medication and also give through intravenously by nurse

Aftet surgery patient have chest tube for collecting fluids or air and drain for removing drainage, amount of the drain recorded by nursr in 24 hours periods

After the few days of surgery a nurse or carepartner help patient in walking but remember patient ambulate or walk with chest tube or drain

Spirometer or pulmonary care for practice of deep breathing its a plastic device and also chest-PT done by physiotherapist for reducing cough and breathing problem 

What are the complications after the surgery?:

Laparoscopic esophagectomy resulted in lower incidence of major complications (specifically, pulmonary complications) during  or after esophagectomy  for cancer than did open surgery, this procedure also resulted in overall sutvival and diseased free survival that ever similar to those observed with open esophagectomy and also secondary -complications are pneumonia, cardiac arrythmias, myocardial infection, anastomosis leak, anastomosis stricture, dysphagia.

After the discharge from the hospital :

If patient experience following 

symptoms or problems then immediately contact the doctor:

-Severe persistent pain not relief by medication and rest.

-Difficulty obtaining medication any new onset of or increased weaknesses numbness or tingling.

-Persistent chills new onset of fever over 101° degree farehnit or night sweat.

-Any redness, swelling drainage, heat or pain around incision. 

-Any new onset of chestpain or shortness of breathing. 

-Any clogging or dislodgement of surgical drain.

After the removing J-tube or feeding tube:

J-tube or feeding tube remove after the 4 weeks to 6 weeks after the esophagectomy then After the esophagectomy food may moves more quickly from stomach into the lowe intestine with certain food this can be lead to problem called dumping causing weakness sweating diarrhoea and abrupt tiredness after by avoiding food with high sugar contain food may also move more slowly after esophagectomy leading to relux or feeling of fullness in the chest after eating this fact can be reduce by chewing well, avoiding certains foods, following soft foods & eating smaller, more frequent & not eating within three hours before bedtime. 

Review 1 to 2 weeks after the discharge from the hospital between this period patient experience any new pain or any symptoms than immediately take appointement with surgeon. 

DURATION OF SURGERY 3 to 6 HOURS.

HOSPITAL STAY 7 Days WHEN PATIENT STABLE FOR DISCHARGE. 

Images source :google 

#Indore

Dr.vivek sharma

MS, DNB (super speciality)

Consultant surgical gastroenterologist

(G.I.& H.P.B. oncology, liver transplant, Advanced laparoscopy & Bariatric surgeon)

For appointment call us-7692976910,