Minimally invasive esophagectomy: thoracoscopic esophageal mobilization for esophageal cancer with the patient in prone position.

BACKGROUND: Surgical resection is the mainstay treatment for resectable esophageal cancer. Minimally invasive esophagectomy is performed with increasing frequency and proves to be a safe and effective surgical alternative to the open technique. Minimally invasive esophagectomy using thoracoscopic esophageal mobilization with the patient in prone position seems to offer some advantages with regard to surgeon ergonomics and clinical outcome. METHODS: Between July 2005 and September 2010, 46 patients (35 men and 11 women) underwent minimally invasive esophagectomy in the prone position at the authors' institution. Three patients had previously undergone a thoracic intervention (one patient had previously undergone left pneumonectomy because of lung cancer). The preoperative indication was squamous cell carcinoma for 35 patients and adenocarcinoma for 11 patients. In one case, the histology of the biopsy samples showed a squamous cell carcinoma with neuroendocrine differentiation. Neoadjuvant treatment was administered to 15 patients. RESULTS: All 46 patients underwent esophagectomy using minimally invasive thoracic mobilization of the esophagus with the patient in prone position. The abdominal stage of intervention was performed by laparoscopy for 37 patients and by laparotomy for 9 patients. No thoracotomic conversion was performed. In all cases, a cervical end-to-side anastomosis was performed using a circular stapler. The mean operative time was 263 min. The median intensive care unit stay was 2 days, and the median postoperative hospital stay was 15 days. The mean number of procured lymph nodes was 13. The perioperative morbidity rate was 37%, and the perioperative mortality rate was 4.4%. CONCLUSIONS: Minimally invasive esophagectomy is safe and technically feasible. It entails a lower mortality rate and a shorter hospital stay than those reported in most open series. Thoracoscopy with the patient in prone position offers results comparable with those obtained using other minimally invasive techniques regarding the number of procured lymph nodes. This technique shows considerable advantages such as improved surgeon ergonomics, increased operative field exposure, and satisfactory respiratory results.

Anatomical variations of the right hepatic veins and their relevance to surgery.

BACKGROUND/AIMS: In a morphological study of the right hepatic veins anatomical characteristics of surgical importance were looked for. METHODOLOGY: 110 cadaveric human livers were prepared by the corrosion casts method. The confluence patterns of the superior right hepatic vein, the hepatocaval confluence, the accessory right hepatic veins and the anastomoses between hepatic veins in the right hemiliver were examined. RESULTS: Four types of the superior right hepatic vein, based on the length of its trunk and the confluence pattern of its main tributaries were determined and their frequency was calculated. Type I was found in 20%, type II in 40%, type III in 25% and type IV in 15%. Accessory right hepatic veins with a minimal caliber of 0.4 cm, which were always present in type IV, were also found in other types, all together in 27% of the casts. The tributary-free part of the superior right hepatic vein at hepatocaval confluence was longer than 1 cm in 77%. In the right hemiliver 109 anastomoses were found in 29/110 liver casts. CONCLUSIONS: Knowing the characteristics of different superior right hepatic vein types and of the accessory right hepatic veins may be useful in segment-oriented liver resections and in right side living donor resections.