纵隔食管癌

Lower esophagus carcinoma can be approached by a full trans-abdominal incision..
January 1990.
Trans-diaphragmatic approach in cardias cancer
Walter Pinotti described in SGO-1982 the trans-diaphragmatic approach to the lower esophagus carcinoma.
We do use a midline abdominal incision. The xiphoid bone is resected.
The round ligament of the liver is divided in between clamps and the falciform ligament divided from the diaphragm.
An extended radical gastrectomy has been planned, including the distal pancreas, spleen and distal esophagus.
The celiac axis is exposed.
The anterior diaphragm is divided to reach the esophagus.
The anterior mediastinum is open
The patient has a progressive dysphasia and the x-rays shows a lower esophagus carcinoma.
By caudal traction of the liver the suspensor ligament is divided.
Two haemostatic sutures are applied to the diaphragmatic veins and this will allow the bloodless anterior-posterior division of the diaphragm.
We can see the pericardium on the top part of the picture transmitting the cardiac beats.
The diaphragm is divided posteriorly but the pleural spaces are not entered.
The distal esophagus is isolated with a Penrose drain and the vagus nerve is partially resected.
A TA-55 stapler closes the duodenum which is divided proximally
The right diaphragm hiatus is divided sequentially between clamps, and away from the tumor
The splenic artery is isolated very close to the celiac axis, doubly ligated and divided.
The left gastric artery is managed in the same manner.
The splenic vein is isolated, ligated twice and divided just before it enters the portal vein.
The pancreas is clamped, divided in proximity and the pancreatic duct and the bleeding vessels sutured with silk
The surgical specimen and the spleen are movilized anteriorly, and we can see the left adrenal gland that is beeing close to the tail of the pancreas.
A Satinsky a traumatic clamp is applied to the proximal esophagus with is divided distally. The excise phase of the operation is finished here and the reconstructive phase started.
Four stay sutures are applied to the distal esophagus and a monofilament whip-stitch used as a purse string. The esophageal lumen is dilated with a Hegar dilator to facilitate the entry of the circular stapler.
An Omega lop of the small bowel is used as a Tanner-19 reconstruction.
The shaft of the ILS-25 stapler is passed through the intestinal lumen and then the head of the stapler introduced into the distal esophagus.
The purse string suture is tied, and the reference stitches cut.
The stapler instrument is fired, and with rotation and traction movements the head of the stapler removed.
The integrity of both doughnuts is confirmed.
The efferent loop of the small bowel I open 15 cm distal of the esophageal anastomosis on the ante-mesenteric border and sutured to the afferent loop opening with a mono-layer interrupted silk stitches.
The anterior phase of the anastomosis is being finished…and then the posterior one.
This figure shows the two finished anastomosis, and the third one is made at least 60 cm away to prevent any bilio-pancreatic reflux.
The antimesenteric border of the bowel is opened and the anterior part of the anastomosis is seen…and then the posterior one.
The three anastomosis are shown now .
The prevent any internal hernias, the mesenteric defects are closed with interrupted sutures of silk

The diaphragmatic defect is closed with interrupted silk stitches.
The afferent loop is included in this suture-line to prevent any diaphragmatic hernias
The rest of the diaphragm is closed with silk.
The anterior diaphragmatic approach of Walter Pinotti allows an excellent exposude of the lower thoracic cavity, acceptable exposude of the psotr¡erioir mediastinum to resct cancers involving the distal esophagus.
The abdomen is being closed with retention sutures of Ventrolfil to prevent hernias formation, the fascias with nylon and the sakin with silk
Draisna ser left on th duodenlstump, the subpherinc space, the anterior mediastinum close to the esophageal-jeunum anastomsois and also in the leaft pleural space.
The operative specimen show sth e distal body and tail of the pancreas, the spleeen and the left adrenal gland.

                               
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