General Surgery · Upper GI

Ivor Lewis Oesophagectomy

OPERATION: Ivor Lewis Oesophagectomy (Laparotomy and Right Thoracotomy with Intrathoracic Anastomosis)
ANAESTHETIC: General anaesthesia — double-lumen endotracheal tube. Thoracic epidural placed pre-operatively.
ANTIBIOTICS: IV antibiotics at induction. VTE prophylaxis from induction.
POSITION: Supine (abdominal phase), then left lateral decubitus (thoracic phase).

INDICATION:
Carcinoma of the distal or mid oesophagus / gastro-oesophageal junction — suitable for intrathoracic anastomosis. Advantages: direct dissection of tumour in chest, good nodal clearance, less recurrent nerve risk than cervical anastomosis. [Preoperative: EUS, CT staging, PET-CT, OGD by surgeon]. [Neoadjuvant chemoradiotherapy completed]. Nutritional assessment — J-tube planned.

PHASE 1 — LAPAROTOMY AND GASTRIC MOBILISATION:
Upper midline laparotomy. Abdominal exploration — metastatic disease excluded. Right gastroepiploic artery palpated — pulse confirmed strong.

Gastric mobilisation identical to McKeown procedure: short gastric vessels divided; left gastric artery divided at origin with endovascular stapler after nodal clearance; greater curvature dissection to the pylorus; Kocher manoeuvre performed fully. Lower thoracic oesophagus dissected transhiatally as far as possible — harmonic scalpel used. [T2 or higher tumour: rim of diaphragm included with the specimen]. Pyloroplasty or pyloromyotomy performed.