Ivor-Lewis esophagogastrectomy with hand-sewn anastomosis by thoracoscopy in prone position and laparoscopy

We present the clinical case of a thoracic esophageal tumor. The objective of this video is to demonstrate our technique of laterolateral esophagogastric anastomosis thoracoscopically during an Ivor-Lewis esophagectomy.

Achalasia stems from Greek and means “a” (not) and “khálasis” (relaxation).
Idiopathic megaesophagus (achalasia) is an esophageal primary motor irregularity. It is characterized by the absence of esophageal peristalsis, together with incomplete relaxation of the lower esophageal sphincter after swallowing.
Differential diagnosis must be made between Chagas disease and esophageal squamous cell carcinoma. The incidence rate ranges from 0.5 to 1 per 100,000 persons-years of study. Although there are several theories, the etiology remains unknown.
The first clinical description was made by Sir Thomas Wills (1672). He used to treat the disease via dilation with a sponge attached to a whalebone. Arthur Hertz was the first to name the disease “achalasia”. Ernest Heller performed the first successful esophagectomy in 1913. Zaaijer was the first to describe the anterior myotomy in 1923.
Other therapeutic procedures include botulinum toxin injection into the lower esophageal sphincter. It has transient effects and patients can develop tolerance to the injections. Another option is endoscopic hydropneumatic dilation, which should be fluoroscopically-guided. When it fails, the efficacy of other therapeutic options decreases. The most serious complication is esophageal perforation.
The diagnostic criteria are based on endoscopic findings. Endoscopy reveals there are food remains as well as esophageal dilation, and decreased motility. X-ray exams show esophageal dilation and narrowing of the lower esophageal sphincter. Manometric findings show decreased esophageal motility, increased lower esophageal sphincter pressure, and incomplete relaxation of the lower esophageal sphincter.
The patient was operated on. Since there was no hiatal hernia, laparoscopic Toupet fundoplication was chosen, based on its efficacy in preventing reflux, as well as in keeping the myotomy free of a wrap.

Achalasia is the most frequent esophageal motility disorder. Although Heller myotomy is the standard treatment, achieving good results in 90 to 95% of cases, esophagectomy could be the last surgical chance to treat end-stage achalasia and might be considered if severe symptomatic (dysphagia, regurgitation), anatomical (megaesophagus) or functional (esophagus aperistalses) disorders are not relieved with a more conservative approach.
Clinical case: We present the case of a 21-year-old female patient suffering from esophageal achalasia from the age of 3. After numerous attempts to grant her a good quality of life in a conservative way, when she gets to end-stage achalasia without any benefits from endoscopic therapies, a minimally invasive Ivor-Lewis esophagectomy is put forward to her in order to relieve her symptoms. Discussion/Conclusion: Esophagectomy could be performed in patients who are fit for major surgery and present with disabling symptoms, poor quality of life, and dolichomegaesophagus unresponsive to multiple endoscopic dilatations and/or surgical myotomies.

Less than 200 cases of internal hernia have been described through the hiatus of Winslow, usually related to congenital or acquired anatomical defects. The most frequent affectation corresponds to the colon, small intestine and, rarely, to the gallbladder. There is usually occlusion with variable grade ischemia, but it can also occur as obstructive jaundice, biliary colic, secondary pancreatitis and non-symptomatic herniation.
The association of Winslow’s hiatus hernia with various anatomical abnormalities (high or subhepatic caecum, mobile ascending colon, large and long colonic mesentery, etc.) may actually correspond to different degrees of intestinal malrotation and, although the diagnosis of “malrotation” is not usually specified, we believe that this could underlie part of Winslow’s hiatus hernia associated with non-acquired anatomical defects.
Hiatal hernia corresponds to 0.2-0.9% of all cases of intestinal obstruction, of which 8% are from Winslow’s hiatus. If pre-surgical diagnosis is difficult, it occurs in less than 10% of cases.
Mortality is around 50% when it has vascular implication. We have not thought of applying the omentum to seal the defect because we did not have adequate surgical anchor sites since we were working millimeters from the vena cava, extrahepatic bile duct, duodenum, and perirenal area. We decided to fix the colon from the hepatic flexure to the right iliac fossa with continuous stitches, from the colonic serosa to Toldt’s fascia, as it is from the embryonic stage.

Early tumors of the esophagogastric junction can be managed with a minimally invasive proximal gastrectomy. This operation has recently been reevaluated for early-stage tumors since it offers a good postoperative quality of life with oncological outcomes equivalent to more extended procedures. In this video, we present the case of a 72-year-old man presenting with a 2cm adenocarcinoma of the esophagogastric junction. The clinical stage of the lesion was T1N0. A laparoscopic proximal gastrectomy with stapled circular esophagogastrostomy was decided upon. Five ports were placed. The left trocar incision was enlarged to introduce the circular stapler for the anastomoses and for specimen extraction. The procedure began with a complete abdominal exploration to rule out peritoneal metastases. The gastrocolic and gastrosplenic ligaments were divided with an ultrasonic scalpel. Short splenic vessels were clipped and divided and the greater curvature completely isolated with careful preservation of the gastroepiploic arcade and of the right gastroepiploic artery and vein. Left gastric vessels were divided at their origin with a vascular stapler and the distal esophagus was isolated through the diaphragmatic hiatus. A gastric tube was created with multiple applications of a linear stapler. The anvil of the circular stapler was secured to the esophageal stump with a hand-sewn purse-string suture in order to avoid the overlap of two suture lines. The esophagogastric anastomosis was then achieved with a circular stapler.