What are the steps of an Ivor Lewis esophagectomy?

Steps of Ivor Lewis Esophagectomy

The Ivor Lewis esophagectomy is performed through laparotomy and right thoracotomy, with the stomach mobilized as a conduit and an upper thoracic esophagogastric anastomosis created at or above the azygos vein. 1

Abdominal Phase (Laparotomy)

1. Patient positioning and access:

   • Supine position for the abdominal portion
   • Midline laparotomy incision (or laparoscopic approach in minimally invasive technique)

2. Stomach mobilization:

   • Complete mobilization of the stomach while preserving blood supply
   • Dissection of the celiac and left gastric lymph nodes
   • Division of the left gastric artery
   • Preservation of the gastroepiploic and right gastric arteries (critical for conduit viability)

3. Gastric conduit creation:

   • Formation of a gastric tube by dividing the stomach along the greater curvature
   • Preservation of the right gastroepiploic arcade which will serve as the primary blood supply

4. Additional abdominal steps:

   • Placement of a feeding jejunostomy tube (optional but recommended)
   • Kocher maneuver to mobilize the duodenum (to ensure tension-free anastomosis)

Thoracic Phase (Right Thoracotomy)

1. Patient repositioning:

   • Repositioning to left lateral decubitus position
   • Right thoracotomy incision (typically at 5th or 6th intercostal space)

2. Esophageal mobilization:

   • Division of the azygos vein
   • Circumferential mobilization of the thoracic esophagus
   • Identification and preservation of the vagus nerves when possible
   • Thorough mediastinal lymph node dissection

3. Esophageal transection:

   • Division of the esophagus above the level of the tumor with adequate proximal margin
   • Removal of the specimen (distal esophagus and proximal stomach)

4. Conduit delivery and anastomosis:

   • Delivery of the gastric conduit into the chest cavity
   • Creation of esophagogastric anastomosis at or above the level of the azygos vein
   • Anastomosis can be performed using stapling devices or hand-sewn techniques

5. Completion:

   • Placement of chest tube(s)
   • Closure of the thoracotomy
   • Closure of the abdominal incision

Minimally Invasive Approach

The Ivor Lewis esophagectomy can also be performed using minimally invasive techniques 2, 3, 4, 5:

1. Laparoscopic abdominal phase:

   • Typically uses 5-6 ports for access
   • Same steps as open procedure but performed laparoscopically

2. Thoracoscopic thoracic phase:

   • Patient positioned in left lateral decubitus position
   • 3-4 thoracoscopic ports
   • Same dissection and anastomotic principles as open procedure

Technical Considerations and Pitfalls

• Anastomotic leak prevention: This is critical as leak rates range from 3-25% with traditional techniques. Modified techniques can reduce this to under 2% 6
• Blood supply preservation: The right gastroepiploic and right gastric arteries must be carefully preserved to maintain conduit viability
• Lymph node dissection: At least 15 lymph nodes should be removed for adequate staging in patients not receiving induction chemoradiation 1
• Conduit length: Ensure adequate length of the gastric conduit to reach the proximal esophagus without tension
• Anastomotic technique: Proper technique is essential to minimize stricture formation, which can occur in up to 40% of cases with traditional methods 6

Appropriate Patient Selection

The Ivor Lewis approach is most appropriate for:

• Tumors of the distal esophagus and gastroesophageal junction
• Cases where adequate proximal margin can be achieved
• Patients who can tolerate both abdominal and thoracic procedures

For tumors in the middle esophagus, the proximal margin may be inadequate with standard Ivor Lewis approach 1.