LAPAROTHORACOSCOPIC ESOPHAGECTOMY IN PRONE POSITION 1. Case report: Patient Nguyen Van A is male, 64 years old.

He had suffered dysphasia for 1 month prior to admission to hospital. An GE endoscopic exam revealed a vegetarian tumor in the middle third of the esophagus. An endo-ultrasonography detected that the tumor had invaded through the muscle layer and that there wasnt any mediastenal nodes. ( T2, N0). A CT scan of the thoracic found a site on the esophagus thicker than usual and about 2cm in length, not yet invading surrounding structure. A laparoscopic esophagectomy in prone position was performed on 10 June 2012.

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Thoracoscopic step:

Patients position and trocart sites: Patient was anasthesed under Carlens intubation in order to keep the right lung prolapse. He lay in prone at an oblique angle of 30o on the right hand side. 3 trocarts 10mm in diameter were inserted align on post auxiliary line at the level of 4,7,9th intercostal spaces. In prone position the right lung must be prolapsed and moved to the anterior leaving spacious path for dissection. Dissection and division of large agygus vein : Meticulous dissection of the large agygus vein; Ligation with stitches of vycryl 2/0; Reinforcement with hemo-lock size L two ends; division of the large agygus vein.

Opening of the mediastenal pleural: incision of the mediastenal pleural with a bistular hook or a harmonic scarlpel (posterior and anterior). The posterior incision being parallel and close to the anterior of the agygous vein; The anterior incision lying on the right side of the bronchus superiory and along the cardiac membrane posteriory. The two incisions meet near the diaphragm and the apex pleural.

Dissection of the posterior face of the esophagus: Use of dissecting Kelly forcept through trocart at the 9th intercostal space to push the esophagus anterior; Separation of the esophagus from the aortic artery with a harmonic scalpel, starting from inferior border large agygus; Cutting of the vein and some esophagus arteries; Dissection of the whole posterior mediastenal lymph nodes. Dissection of the anterior face of the esophagus: Use of dissecting Kelly forcept to raise the esophagus and separate the anterior face of the esophagus from the cardiac membrane. The separation appears simple as no blood vessel is available there. Creation of a window around the esophagus: Use of a blunt dissecting forcept to create a window around the low portion of the esophagus and dissection of the posterior face of esophagus. That window facilitates the prevention of hemorrhage; Cutting of all other vessels coming from the aortic artery and the vagus nerve. Dissection of the lymph nodes in broncho-trachea bifurcation: Raise of the esophagus and dissection of the lymph nodes beneath the bifurcation of broncho tracheal and the accompanied portion of the esophagus ;

Dissection of the lymph nodes together with the accompanied portion of the esophagus is easier then the dissection of the nodes separately. Separation of the esophagus from the posterior brocho trachea: Raise of the esophagus and separation of it from the posterior broncho-trachea up to the apex pleural; Dissection of para tracheal lymph nodes; Irrigation and suction of thoracic cavity with saline , coagulation, laying of a silicon drainage tube and expansion of pulmon.

3. Laparoscopic step:
Position, trocart sites and peritoneal inflation: The patient was repositioned to supine with left arm lying along the body, right arm stretching at an angle of 900 and legs open. Use of 5 trocarts and peritoneal inflation at 12 mmHg. The surgeon stood between patients legs. The first assistant holding a camera was on the right, and the second assistant on the left.

Dissection of the great gastric curvature: Cutting of the outside acard of right gatroepiploic artery with a harmonic scalpel, from the center to right and left;

Cutting and coagulation of the vessels in omentum and the short gastric arteries in spleen gastric ligament with a harmonic scalpel. Removal of lesser omentum from pyloric to right side of abdominal esophagus . Dissection of lymph nodes at dorsal pancreas and cutting of left gastric vein and artery with a harmonic sarlpel. Dissection of lymph nodes around body and tail of pancreas. Complete disection the left artery and vein so clear that can put hemo-lock and divide at its origine. Dissection of the abdominal esophagus to thoracic orifice through hiatal. Cutting of the right column of hiatal diaphragm and enlargement of the mediastenal as tunel for the introduction of the gastric conduit.

4. Abdominal and neck steps:

Incision of neck on the left before sternoclavicule muscle; exclusion of the esophagus and division of it at a place at least 1cm above the sternum notch . Minilaparotomy and creation of gastric conduit: Making of a 5-cm opening close to the sternum;

Taking of the esophagus and the stomach from the abdomen to make gastric conduit with stapler LC or GIA. Introduction of the gastric conduit to the level of neck and creation of an esophagogastric anastomosis, one layer continuous end to side with PDS 3/0. Creation of a Witzel-style jejunostomy for nutrition. 4.Postoperation: Operation time was 230 seconds Blood lost estimated 100ml. Time of stay in ICU was 1 day. Gastrografin-swallow X-ray exam on post-operation day 7 was regular. Histology finding was Squamous cell carcinoma and pT2N0M0 ( 12 nodes was involved). The patient was discharged on post-op day 8.