Surgical procedures can be divided into open and closed (minimally invasive).
In open surgical procedures, the surgeon makes larger incisions in the skin and thus exposes the surgical area. The procedure is therefore performed on an open body.
A minimally invasive procedure is closed instead. Only small skin incisions are required. Miniaturized, endoscopic instruments are inserted through these incisions, such as
- forceps,
- scissors,
- irrigation and suction devices,
- suturing instruments and
- a video camera.
The video system displays an image - in some cases even three-dimensionally - on a monitor. This provides a clear view of the surgical site. Minimally invasive, endoscopic procedures in the abdominal cavity are called laparoscopy and thoracoscopy in the chest.
The oesophagus connects the throat to the stomach © SciePro| AdobeStock
From a functional point of view, the oesophagus is a fairly simple organ. It transports food from the mouth to the stomach. However, it is difficult to access surgically behind the lungs. There is a risk during an operation,
- the lung,
- nearby large blood vessels,
- the spleen or
- the diaphragm
or the diaphragm. For this reason, esophageal operations represent a complex challenge from a surgical point of view and are fraught with complications.
Minimally invasive surgery results in fewer complications due to the smaller number of surgical injuries. This is why minimally invasive surgery in the area of the oesophagus is now a standard procedure.
In addition to the reduced risk of complications, minimally invasive procedures generally have the following advantages over open procedures:
- Less pain after surgery, allowing the patient to get up and move around sooner. This reduces the risk of thrombosis.
- Earlier discharge from hospital.
- Better cosmetic result due to smaller scars.
- Fewer wound healing disorders occur.
Today, most patients with diseases of the oesophagus can be treated using minimally invasive surgery.
In some cases, however, minimally invasive surgery is not possible. This means that the procedure must be performed openly. The following contraindications speak against minimally invasive surgery:
- Adhesions and adhesions after previous operations
- Infections on the skin or abdominal wall
- Inflammation of the peritoneum (peritonitis) or pleura (pleuritis)
- Blood clotting disorders that cannot be controlled
- Heart or lung diseases that are associated with a higher risk of anesthesia.
Atypical area of application for minimally invasive esophageal surgery is the treatment of
Other areas of application include
- Esophageal malformations
- Injuries to the oesophagus
- Hiatal hernia(diaphragmatic hernia): Parts of the stomach protrude through the opening in the diaphragm through which the esophagus passes
- Achalasia: inability of the lower esophageal sphincter to open sufficiently for food to pass through into the stomach
- Diverticula (protrusions) of the oesophagus
- Benign tumors of the esophageal muscles (leiomyomas)
In the case of advanced esophageal cancer, partial or complete removal of the esophagus is usually necessary. This is called esophageal resection or esophagectomy. The lymph nodes of the abdomen and chest are often not allowed to remain in the body either.
The aim is to completely remove the tumor and create a new connection between the mouth and stomach or intestine.
Possible procedures
Two methods have been established for this purpose
- open surgery,
- completely minimally invasive or
- partially open and partially minimally invasive (hybrid procedure)
can be performed:
- transhiatal esophagectomy (surgery via the abdominal cavity and neck)
- transthoracic esophagectomy (operation via the abdomen and chest cavity)
Transhiatal esophagectomy is mostly used for patients with lung damage and then as an open surgical variant. In difficult cases, either the hybrid procedure or the completely open surgical variant is also used.
Performing thoracoscopic-laparoscopic esophageal resection
Due to the slightly better chance of survival, many centers perform transthoracic esophagectomy in a minimally invasive manner. This is also known as thoracoscopic-laparoscopic esophagectomy.
This is a combination of two endoscopic procedures:
- a laparoscopy (endoscopy in the abdominal cavity) and
- a thoracoscopy (endoscopy in the chest cavity).
The procedure begins as a laparoscopy. In the supine position, the surgeon inserts the endoscopic instruments into the body via five small incisions in the abdomen. He then exposes the lower oesophagus with the surrounding lymph nodes. He then reshapes the stomach into a tube so that it can later be connected to the oesophagus remaining in the body. Finally, the surgeon removes the instruments from the body and sutures the access points.
For the subsequent thoracoscopy, the patient is positioned on their side. Five skin incisions are also necessary here, this time on the chest. The surgeon now detaches the oesophagus from the surrounding tissue to just below the neck, including the lymph nodes.
Exposing the oesophagus is difficult due to the close connection
- to the aorta,
- to the pericardium,
- to the main bronchi and
- to the trachea
very complex. If the tumor is located in the neck part of the esophagus, the neck must also be dissected. In most cases, however, the neck part of the oesophagus can remain in the body. The procedure is therefore limited to the chest cavity.
The surgeon now pulls the stomach tube prepared in the first step up into the chest cavity. He removes the oesophagus together with the lymph nodes from the body via a skin incision about five centimetres long. He then connects the stomach tube to the remaining esophagus.
Once the endoscopic instruments have been removed, the accesses are closed.
Patients with oesophageal cancer require special follow-up care in order to detect any recurrence of the cancer in good time.
Minimally invasive reflux therapy, known as anti-reflux surgery, is also a common procedure.
The cause of reflux is usually a hiatal hernia with the entrance to the stomach sliding up into the chest next to the oesophagus. As a result, the closure mechanism at the junction of the oesophagus and stomach no longer functions correctly and acidic stomach contents flow into the oesophagus.
Illustration of the healthy stomach (left) and the stomach affected by reflux (right). The diaphragm is the cover above the stomach © bilderzwerg | AdobeStock
Laparoscopic antireflux surgery (LARO ) is recommended for patients
- who respond to treatment with proton pump inhibitors but do not tolerate them
- who have reflux symptoms despite treatment with proton pump inhibitors, in particular reflux of chyme into the oral cavity
- who show atypical reflux symptoms despite treatment with proton pump inhibitors, such as chronic cough, recurrent sinusitis, asthma, sleep-related breathing disorders, hoarseness, tooth erosion and chest pain.
However, if atypical reflux symptoms are in the foreground, the chances of success of LARO are significantly reduced. LARO is also less suitable or may not be suitable for patients with
After inserting the laparoscopic instruments, the surgeon narrows the widened diaphragmatic hiatus. A mesh (hiatoplasty) is often used for this.
The surgeon then wraps the stomach dome around the lowest part of the oesophagus in the form of a sleeve(fundoplication). The sleeve can be
- complete (laparoscopic fundoplication according to Nissen) - the most commonly used variant,
- partially (laparoscopic fundoplication according to Toupet) or
- only in the anterior region (laparoscopic fundoplication according to Dor) - the least frequently used variant)
can be applied.
After removal of the esophagus, normal feeding via the mouth is initially no longer possible. Instead, food concentrates are given directly into the intestine, possibly for several months. The patient can counteract malnutrition by administering high-energy solutions.
If chyme enters the small intestine too quickly, this can lead to
- unpleasant feeling of fullness,
- diarrhea,
- pain,
- sweating and
- trembling
can occur. Those affected can prevent this dumping syndrome by consciously eating and drinking. Care should be taken to
- eat slowly,
- chew thoroughly,
- not "wash down" the food with drink and avoid
- avoid liquid foods.
In the case of a fundoplication, the patient can usually eat a light diet the day after the operation. From the third day onwards, they can usually eat normally again.
Patients who have undergone minimally invasive surgery may have to change their diet depending on their condition. For this reason, they usually receive nutritional advice. They may not feel hungry for some time and will have to divide their food and fluid intake into several small individual portions.
In principle, there is no standard diet; each patient tries out their own options.
There are general risks associated with every operation . These include, for example
In addition, there are specific risks of complications due to the typical characteristics of minimally invasive surgery. For example, the insertion of endoscopic instruments can lead to bleeding and tears in neighboring tissues.
As air is blown in during a minimally invasive procedure, air can accumulate in the skin (skin emphysema). In addition, complications can develop in the heart, lungs and blood flow due to the increase in pressure.
In rare cases, laparoscopic anti-reflux surgery can lead to
- Injuries, particularly to the spleen and other organs,
- slippage or disintegration of the cuff into the chest cavity,
- respiratory (breathing) complications and
- swallowing disorders
can occur.
Organ-specific injuries can also occur during esophagectomy. It is serious if the connection between the oesophagus and the stomach tube becomes leaky. This can lead to pneumonia.
Overall, however, the chances of success and prognosis after minimally invasive surgery on the oesophagus are very good. Most patients regain a largely normal quality of life after fundoplication.
The operation should be performed by experienced surgeons at specialized centers.
