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Thoracoabdominal incision: a forgotten tool in the management of complex upper gastrointestinal complications
The American Journal of Surgery (2009) 197, e28 – e31
How I Do It
Thoracoabdominal incision: a forgotten tool in the management of complex upper gastrointestinal complications Luis Jose Garcia, M.D., Diego Mauricio Avella, M.D., Brett Hartman, D.O., Eric Kimchi, M.D., Kevin Finnbar Staveley-O’Carroll, M.D., Ph.D.* Department of Surgery, Section of Surgical Oncology, 500 University Dr., Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA KEYWORDS: Thoracoabdominal incision; Gastroesophageal junction; Surgical complications
Abstract BACKGROUND: The gastroesophageal junction was commonly approached surgically through a thoracoabdominal incision. With the advent of improved retraction devices, this has been abandoned because the upper midline incision has provided adequate exposure with decreased morbidity. However, exposure of the gastroesophageal junction remains a challenge in the setting of surgical complications associated with repeat surgeries and abscess formation. METHODS: Patients were placed in the right lateral decubitus position. An incision was made 2 cm below the tip of the scapula to a point in the midline equidistant from the xiphoid process to the umbilicus. The chest was entered at the eighth intercostal space. The abdominal cavity was entered by dividing the diaphragm peripherally from its lateral attachments to the ribs. RESULTS: We have used this approach on 4 patients. All patients were discharged home tolerating oral diets. The average postoperative stay was 10 days. No complications related to the incision were reported. At the 6-month follow-up evaluation all patients continued to tolerate a regular diet without difficulties. CONCLUSIONS: The technique described allows for excellent exposure of the upper gastrointestinal tract in a subset of patients with complex upper gastrointestinal complications. © 2009 Elsevier Inc. All rights reserved.
For years, the gastroesophageal junction (GEJ) was commonly approached surgically through a thoracoabdominal incision.1 With the advent of improved retraction devices, this largely has been abandoned because the upper midline incision has provided adequate exposure with decreased morbidity.2 However, exposure of the GEJ remains a challenge in the setting of surgical complications associated with repeat surgeries and abscess formation. In such circumstances, a transab* Corresponding author: Tel.: ⫹1-717-531-7405; fax: ⫹1-717-5313649. E-mail address: [email protected] Manuscript received January 9, 2008; revised manuscript June 9, 2008
0002-9610/$ - see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.06.032
dominal approach can be unsuccessful, particularly if the process extends significantly through the hiatus along the esophagus. We report the use of a thoracoabdominal incision to facilitate anatomic exposure in these difficult cases. We describe 4 patients who have undergone this procedure and are enjoying excellent functional outcomes (Table 1).
Patients and Methods Four patients who had developed complications after procedures involving the upper gastrointestinal (GI) tract
L.J. Garcia et al. Table 1
Thoracoabdominal incision in GI complications
Outcomes of 4 patients with complex upper GI complications
Patient age, y/sex Problem 57/F
65/F 61/F
59/F
e29
Esophageal erosion of Gore-Tex mesh (W.L. Gore & Associates, Flagstaff, AZ USA) placed after failed Nissen’s fundoplication Long posterior esophageal tear during completion gastrectomy Posterior gastric wall necrosis, proximal gastrectomy, cervical esophagostomy Gastrojejunal anastomotic perforation s/p laparoscopic gastric bypass, gastric pouch excision, cervical esophagostomy
Treatment
Outcomes
Esophagectomy/proximal gastrectomy with short-segment colon interposition
6 mo: maintaining weight and enjoying a regular diet
Distal esophagectomy with colon interposition 3 mo: maintaining weight and to a roux-en-Y jejunal pouch enjoying a regular diet Roux-en-Y with long jejunal limb intrathoracic 6 mo: maintaining weight and reconstruction enjoying a regular diet Colon interposition between esophagus and distal gastric remnant
who subsequently required further surgical intervention were referred to our practice. The following morbidities were included: (1) long posterior esophageal tear during a completion gastrectomy; (2) esophageal erosion of polytetrafluoroethylene mesh placed during paraesophageal hernia repair after a failed Nissen’s fundoplication; (3) gastrojejunal anastomotic perforation after laparoscopic gastric bypass surgery subsequently treated with 3 explorations, gastric pouch excision, stapling of the distal esophagus, and cervical esophagostomy; and (4) posterior gastric wall necrosis initially treated with proximal gastrectomy, stapling of the distal esophagus, and cervical esophagostomy. All patients, after successful induction of general anesthesia, were placed in the right lateral decubitus position. Single-lung ventilation aided exposure, but it was not strictly required because the lung can be packed adequately and retracted. Safety measures to minimize the chance of nerve injury with the patient in this position must not be overlooked. An axillary roll made up of a rolled bed sheet, towel, wrapped saline bag, or silicone bump, are all appropriate choices. In addition, it is important to position the patient’s legs with the bottom leg bent at the knee and the top leg straightened with a pillow between the legs. To optimize exposure, we maximally flexed the bed at the level of the patient’s iliac crest. It is essential to prepare the surgical field so that the abdomen is exposed as far as possible past the midline of the abdomen and back to allow for the proper incision. Once sterile towels are placed to square off the surgical field, an adhesive drape is placed over the surgical site and then the final drapes are placed. An incision was made from a point 2 cm below the tip of the left scapula to a point in the midline of the abdomen equidistant from the xiphoid process and the umbilicus (Fig. 1). The incision was deepened, preserving the latissimus and incising the serratus anterior muscle. The chest was entered at the eighth intercostal space. The pulmonary ligament was divided and the lung was mobilized and retracted cephalad and medially out of the field, allowing for exposure of the intrathoracic aorta and esophagus. Subsequently,
6 mo: maintaining weight and enjoying a regular diet
the abdominal cavity was entered by dividing the diaphragm peripherally, 1 to 2 in from its lateral and anterior attachments to the ribs, using electrocautery (Fig. 2). Periodic
Figure 1 Patient placed in the right lateral decubitus position. A thoracoabdominal incision is depicted, extending from a point 2 cm below the tip of the left scapula to a point in the midline equidistant from the xiphoid process and the umbilicus.
e30
The American Journal of Surgery, Vol 197, No 2, February 2009 proximating the abdominal wall muscle and fascia en mass using a running no. 1 PDS suture. The chest wall musculature was closed in 2 layers using running no. 1 Vicryl sutures, and the skin was approximated with surgical clips.
Results
Figure 2 Viewing from above the cross-section of the diaphragm, the hatched line represents the circumferential incision made along the peripheral edge of the diaphragm. This avoids injury to the phrenic nerve and allows entry from the thoracic cavity into the abdominal cavity to create a common cavity for the thorax and peritoneum.
placement of marking stitches on the divided diaphragm was very helpful when aligning the diaphragm at closure. Typically, a portion of the costochondral cartilage was excised to prevent postoperative costochondritis. The abdominal incision was opened to the linea alba at a point equidistant from the xiphoid process to the umbilicus. The abdominal wall muscles were divided and the peritoneum was entered. Exposure was aided by placement of a segmental self-retaining retractor. This provided excellent exposure to the intrathoracic esophagus, GEJ, and the abdominal viscera (Fig. 3). Closure was aided by taking the bed out of the flexed position. The diaphragmatic repair was performed first using a no. 1 PDS (polydioxanone, Ethicon, Inc., Piscataway, NJ USA) suture; appropriate alignment of the diaphragm was facilitated by the marking stitches placed earlier. A difficult area was encountered at the junction of the diaphragm and the abdominal fascia; this inherently weak area is difficult to reapproximate and may lead to an abdominal wall or diaphragmatic hernia. An en masse closure incorporating the ribs, diaphragm, and abdominal wall muscle with a no. 2 Vicryl (Ethicon, Inc.,) figure-of-eight suture can be helpful in strengthening this area. Similarly, the ribs were reapproximated using interrupted no. 2 Vicryl figure-ofeight sutures. The abdominal wound was closed by reap-
We have used this approach on 4 patients with excellent clinical results (Table 1). Three patients were reconstructed with a short-segment colonic interposition using the splenic flexure; one was reconstructed with a long jejunal limb. Follow-up Gastrografin (Bracco Diagnostics, Inc., Princeton, NJ USA) swallow studies were obtained in all patients, and all showed no evidence of anastomotic leak or stricture. Three patients were discharged to home tolerating oral diets without difficulty. One patient had moderate feeding intolerance postoperatively and was discharged home on total parenteral nutrition. That patient subsequently was able to be weaned off of her total parenteral nutrition and has resumed an oral diet. All patients are now maintaining their weight on a regular diet without supplemental nutrition. Postoperative stays ranged from 7 to 14 days, with an average postoperative stay of 10 days. Three patients had no complications related to the incision. One patient developed a superficial wound infection that resolved promptly with local drainage and antibiotics. None has developed problems associated with the thoracoabdominal incision such as chronic pain or diaphragmatic hernia.
Figure 3 The exposure achieved from a thoracoabdominal incision with a patient in the right lateral decubitus position. The diaphragm has been incised radially and retracted cephalad, allowing for exposure of the gastroesophageal junction, intra-abdominal viscera, and intrathoracic esophagus.
L.J. Garcia et al.
Thoracoabdominal incision in GI complications
Comments General surgeons routinely perform procedures involving the upper GI tract, such as gastric bypass surgery, Nissen’s fundoplication, gastric resections, and a variety of emergent procedures. These surgical procedures, especially in the emergent setting, can carry significant morbidity, sometimes requiring multiple reoperations. Surgical intervention in these challenging patients is often quite difficult because of previous abscess formation, adhesive disease, or other pathologic processes involving both the thoracic and abdominal cavities.3 Periodically, when adequate visualization of the GEJ and distal esophagus from a midline incision cannot be obtained, the incision is extended from the xiphoid process through the costochondral cartilage and into an upper intercostal space to create a thoracoabdominal incision. We do not advocate this approach for upper GI procedures because the heart continues to impede access to the posterior mediastinum in the supine position. We were faced with this problem with one of the patients described in this series: the surgeon, performing the procedure through an upper midline incision, had encountered a long esophageal tear extending well into the thorax after performing a completion gastrectomy. In this case, we closed the upper aspect of the midline incision to a point midway between the umbilicus and the xiphoid process, placed an adhesive dressing over the wound, repositioned the patient in the right lateral decubitus position, and then proceeded with the incision described earlier, allowing reconstruction with a short-seg-
e31
ment colon interposition between the esophagus and the jejunal pouch. Although the thoracoabdominal incision occasionally is used by surgical oncologists and thoracic surgeons, it largely has been abandoned by general surgeons.4 This exposure, as described earlier, allows for excellent visualization of the upper abdominal GI tract and lower thoracic esophagus; as such, it is a useful tool that should be maintained in the repertoire of general surgeons performing upper GI procedures. We believe that this technique is particularly useful in the subset of patients who develop complex upper GI tract complications. In addition, we propose that this incision can be used with acceptably low morbidity.
References 1. Cameron J. Atlas of Surgery: The Esophagus, the Stomach, the Duodenum, the Spleen, Laparoscopic Cholecystectomy. Baltimore: Williams and Wilkins; 1991. 2. Wayman J, Dresner SM, Raimes SA, et al. Transhiatal approach to total gastrectomy for adenocarcinoma of the gastric cardia. Br J Surg 1999; 86:536 – 40. 3. Koniaris LG, Spector SA, Staveley-O’Carroll KF. Complete esophageal diversion: a simplified, easily reversible technique. J Am Coll Surg 2004;199:991–3. 4. Forshaw MJ, Gossage JA, Ockrim J, et al. Left thoracoabdominal esophagogastrectomy: still a valid operation for carcinoma of the distal esophagus and esophagogastric junction. Dis Esophagus 2006;19: 340 –5.
How I Do It
Thoracoabdominal incision: a forgotten tool in the management of complex upper gastrointestinal complications Luis Jose Garcia, M.D., Diego Mauricio Avella, M.D., Brett Hartman, D.O., Eric Kimchi, M.D., Kevin Finnbar Staveley-O’Carroll, M.D., Ph.D.* Department of Surgery, Section of Surgical Oncology, 500 University Dr., Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA KEYWORDS: Thoracoabdominal incision; Gastroesophageal junction; Surgical complications
Abstract BACKGROUND: The gastroesophageal junction was commonly approached surgically through a thoracoabdominal incision. With the advent of improved retraction devices, this has been abandoned because the upper midline incision has provided adequate exposure with decreased morbidity. However, exposure of the gastroesophageal junction remains a challenge in the setting of surgical complications associated with repeat surgeries and abscess formation. METHODS: Patients were placed in the right lateral decubitus position. An incision was made 2 cm below the tip of the scapula to a point in the midline equidistant from the xiphoid process to the umbilicus. The chest was entered at the eighth intercostal space. The abdominal cavity was entered by dividing the diaphragm peripherally from its lateral attachments to the ribs. RESULTS: We have used this approach on 4 patients. All patients were discharged home tolerating oral diets. The average postoperative stay was 10 days. No complications related to the incision were reported. At the 6-month follow-up evaluation all patients continued to tolerate a regular diet without difficulties. CONCLUSIONS: The technique described allows for excellent exposure of the upper gastrointestinal tract in a subset of patients with complex upper gastrointestinal complications. © 2009 Elsevier Inc. All rights reserved.
For years, the gastroesophageal junction (GEJ) was commonly approached surgically through a thoracoabdominal incision.1 With the advent of improved retraction devices, this largely has been abandoned because the upper midline incision has provided adequate exposure with decreased morbidity.2 However, exposure of the GEJ remains a challenge in the setting of surgical complications associated with repeat surgeries and abscess formation. In such circumstances, a transab* Corresponding author: Tel.: ⫹1-717-531-7405; fax: ⫹1-717-5313649. E-mail address: [email protected] Manuscript received January 9, 2008; revised manuscript June 9, 2008
0002-9610/$ - see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.06.032
dominal approach can be unsuccessful, particularly if the process extends significantly through the hiatus along the esophagus. We report the use of a thoracoabdominal incision to facilitate anatomic exposure in these difficult cases. We describe 4 patients who have undergone this procedure and are enjoying excellent functional outcomes (Table 1).
Patients and Methods Four patients who had developed complications after procedures involving the upper gastrointestinal (GI) tract
L.J. Garcia et al. Table 1
Thoracoabdominal incision in GI complications
Outcomes of 4 patients with complex upper GI complications
Patient age, y/sex Problem 57/F
65/F 61/F
59/F
e29
Esophageal erosion of Gore-Tex mesh (W.L. Gore & Associates, Flagstaff, AZ USA) placed after failed Nissen’s fundoplication Long posterior esophageal tear during completion gastrectomy Posterior gastric wall necrosis, proximal gastrectomy, cervical esophagostomy Gastrojejunal anastomotic perforation s/p laparoscopic gastric bypass, gastric pouch excision, cervical esophagostomy
Treatment
Outcomes
Esophagectomy/proximal gastrectomy with short-segment colon interposition
6 mo: maintaining weight and enjoying a regular diet
Distal esophagectomy with colon interposition 3 mo: maintaining weight and to a roux-en-Y jejunal pouch enjoying a regular diet Roux-en-Y with long jejunal limb intrathoracic 6 mo: maintaining weight and reconstruction enjoying a regular diet Colon interposition between esophagus and distal gastric remnant
who subsequently required further surgical intervention were referred to our practice. The following morbidities were included: (1) long posterior esophageal tear during a completion gastrectomy; (2) esophageal erosion of polytetrafluoroethylene mesh placed during paraesophageal hernia repair after a failed Nissen’s fundoplication; (3) gastrojejunal anastomotic perforation after laparoscopic gastric bypass surgery subsequently treated with 3 explorations, gastric pouch excision, stapling of the distal esophagus, and cervical esophagostomy; and (4) posterior gastric wall necrosis initially treated with proximal gastrectomy, stapling of the distal esophagus, and cervical esophagostomy. All patients, after successful induction of general anesthesia, were placed in the right lateral decubitus position. Single-lung ventilation aided exposure, but it was not strictly required because the lung can be packed adequately and retracted. Safety measures to minimize the chance of nerve injury with the patient in this position must not be overlooked. An axillary roll made up of a rolled bed sheet, towel, wrapped saline bag, or silicone bump, are all appropriate choices. In addition, it is important to position the patient’s legs with the bottom leg bent at the knee and the top leg straightened with a pillow between the legs. To optimize exposure, we maximally flexed the bed at the level of the patient’s iliac crest. It is essential to prepare the surgical field so that the abdomen is exposed as far as possible past the midline of the abdomen and back to allow for the proper incision. Once sterile towels are placed to square off the surgical field, an adhesive drape is placed over the surgical site and then the final drapes are placed. An incision was made from a point 2 cm below the tip of the left scapula to a point in the midline of the abdomen equidistant from the xiphoid process and the umbilicus (Fig. 1). The incision was deepened, preserving the latissimus and incising the serratus anterior muscle. The chest was entered at the eighth intercostal space. The pulmonary ligament was divided and the lung was mobilized and retracted cephalad and medially out of the field, allowing for exposure of the intrathoracic aorta and esophagus. Subsequently,
6 mo: maintaining weight and enjoying a regular diet
the abdominal cavity was entered by dividing the diaphragm peripherally, 1 to 2 in from its lateral and anterior attachments to the ribs, using electrocautery (Fig. 2). Periodic
Figure 1 Patient placed in the right lateral decubitus position. A thoracoabdominal incision is depicted, extending from a point 2 cm below the tip of the left scapula to a point in the midline equidistant from the xiphoid process and the umbilicus.
e30
The American Journal of Surgery, Vol 197, No 2, February 2009 proximating the abdominal wall muscle and fascia en mass using a running no. 1 PDS suture. The chest wall musculature was closed in 2 layers using running no. 1 Vicryl sutures, and the skin was approximated with surgical clips.
Results
Figure 2 Viewing from above the cross-section of the diaphragm, the hatched line represents the circumferential incision made along the peripheral edge of the diaphragm. This avoids injury to the phrenic nerve and allows entry from the thoracic cavity into the abdominal cavity to create a common cavity for the thorax and peritoneum.
placement of marking stitches on the divided diaphragm was very helpful when aligning the diaphragm at closure. Typically, a portion of the costochondral cartilage was excised to prevent postoperative costochondritis. The abdominal incision was opened to the linea alba at a point equidistant from the xiphoid process to the umbilicus. The abdominal wall muscles were divided and the peritoneum was entered. Exposure was aided by placement of a segmental self-retaining retractor. This provided excellent exposure to the intrathoracic esophagus, GEJ, and the abdominal viscera (Fig. 3). Closure was aided by taking the bed out of the flexed position. The diaphragmatic repair was performed first using a no. 1 PDS (polydioxanone, Ethicon, Inc., Piscataway, NJ USA) suture; appropriate alignment of the diaphragm was facilitated by the marking stitches placed earlier. A difficult area was encountered at the junction of the diaphragm and the abdominal fascia; this inherently weak area is difficult to reapproximate and may lead to an abdominal wall or diaphragmatic hernia. An en masse closure incorporating the ribs, diaphragm, and abdominal wall muscle with a no. 2 Vicryl (Ethicon, Inc.,) figure-of-eight suture can be helpful in strengthening this area. Similarly, the ribs were reapproximated using interrupted no. 2 Vicryl figure-ofeight sutures. The abdominal wound was closed by reap-
We have used this approach on 4 patients with excellent clinical results (Table 1). Three patients were reconstructed with a short-segment colonic interposition using the splenic flexure; one was reconstructed with a long jejunal limb. Follow-up Gastrografin (Bracco Diagnostics, Inc., Princeton, NJ USA) swallow studies were obtained in all patients, and all showed no evidence of anastomotic leak or stricture. Three patients were discharged to home tolerating oral diets without difficulty. One patient had moderate feeding intolerance postoperatively and was discharged home on total parenteral nutrition. That patient subsequently was able to be weaned off of her total parenteral nutrition and has resumed an oral diet. All patients are now maintaining their weight on a regular diet without supplemental nutrition. Postoperative stays ranged from 7 to 14 days, with an average postoperative stay of 10 days. Three patients had no complications related to the incision. One patient developed a superficial wound infection that resolved promptly with local drainage and antibiotics. None has developed problems associated with the thoracoabdominal incision such as chronic pain or diaphragmatic hernia.
Figure 3 The exposure achieved from a thoracoabdominal incision with a patient in the right lateral decubitus position. The diaphragm has been incised radially and retracted cephalad, allowing for exposure of the gastroesophageal junction, intra-abdominal viscera, and intrathoracic esophagus.
L.J. Garcia et al.
Thoracoabdominal incision in GI complications
Comments General surgeons routinely perform procedures involving the upper GI tract, such as gastric bypass surgery, Nissen’s fundoplication, gastric resections, and a variety of emergent procedures. These surgical procedures, especially in the emergent setting, can carry significant morbidity, sometimes requiring multiple reoperations. Surgical intervention in these challenging patients is often quite difficult because of previous abscess formation, adhesive disease, or other pathologic processes involving both the thoracic and abdominal cavities.3 Periodically, when adequate visualization of the GEJ and distal esophagus from a midline incision cannot be obtained, the incision is extended from the xiphoid process through the costochondral cartilage and into an upper intercostal space to create a thoracoabdominal incision. We do not advocate this approach for upper GI procedures because the heart continues to impede access to the posterior mediastinum in the supine position. We were faced with this problem with one of the patients described in this series: the surgeon, performing the procedure through an upper midline incision, had encountered a long esophageal tear extending well into the thorax after performing a completion gastrectomy. In this case, we closed the upper aspect of the midline incision to a point midway between the umbilicus and the xiphoid process, placed an adhesive dressing over the wound, repositioned the patient in the right lateral decubitus position, and then proceeded with the incision described earlier, allowing reconstruction with a short-seg-
e31
ment colon interposition between the esophagus and the jejunal pouch. Although the thoracoabdominal incision occasionally is used by surgical oncologists and thoracic surgeons, it largely has been abandoned by general surgeons.4 This exposure, as described earlier, allows for excellent visualization of the upper abdominal GI tract and lower thoracic esophagus; as such, it is a useful tool that should be maintained in the repertoire of general surgeons performing upper GI procedures. We believe that this technique is particularly useful in the subset of patients who develop complex upper GI tract complications. In addition, we propose that this incision can be used with acceptably low morbidity.
References 1. Cameron J. Atlas of Surgery: The Esophagus, the Stomach, the Duodenum, the Spleen, Laparoscopic Cholecystectomy. Baltimore: Williams and Wilkins; 1991. 2. Wayman J, Dresner SM, Raimes SA, et al. Transhiatal approach to total gastrectomy for adenocarcinoma of the gastric cardia. Br J Surg 1999; 86:536 – 40. 3. Koniaris LG, Spector SA, Staveley-O’Carroll KF. Complete esophageal diversion: a simplified, easily reversible technique. J Am Coll Surg 2004;199:991–3. 4. Forshaw MJ, Gossage JA, Ockrim J, et al. Left thoracoabdominal esophagogastrectomy: still a valid operation for carcinoma of the distal esophagus and esophagogastric junction. Dis Esophagus 2006;19: 340 –5.