Appendix 3Oesophagectomy manual (essential tasks)
Abdominal phase
Abdominal access
- 1.
Confirm the absence of metastatic disease.
Diaphragmatic hiatus
- 2.
Mobilise the gastro-oesophageal junction, resecting right and left paracardial lymphatic (LN) tissue (LN stations 1 and 2).
- 3.
Resect a cuff of diaphragm and pleura to achieve a clear circumferential margin in advanced disease.
- 4.
Dissect along the pre-aortic fascia.
Gastric mobilisation
- 5.
Mobilise the stomach based on the right gastroepiploic vessels.
Coeliac axis
- 6.
Dissect LN tissue along the common hepatic artery, coeliac artery, left gastric artery and proximal splenic artery (LN stations 7, 8a, 9 and 11p).
- 7.
Ligate and divide the left gastric vein close to the portal vein and the left gastric artery at the coeliac artery.
- 8.
Dissect LN tissue from the left side of the coeliac artery to the left crus at the oesophageal hiatus and the left side of Gerota’s fascia.
- 9.
Continue the dissection along the anterior surface of the proximal splenic artery towards the splenic hilum and ligate the posterior gastric vessels at their origin from the splenic artery.
Gastric tube
- 10.
Create the gastric tube, removing tissue along the lesser curvature of the stomach (LN stations 3a and 3b). This step may be carried out in the chest.
Thoracic phase
Thoracic access
- 1.
Exclude metastatic disease in the chest.
Thoracic lymphadenectomy
- 2.
Divide the inferior pulmonary ligament and ligate and divide the azygos arch.
- 3.
Dissect along the pericardium until the left pulmonary vein is reached, including the left pleura in advanced disease.
- 4.
Perform a subcarinal lymphadenectomy (LN station 107) and clear both bronchi of LN tissue (LN station 109).
- 5.
Dissect the mediastinal pleura at the anterolateral border of the thoracic aorta and dissect along the pre-aortic fascia from the proximal resection margin towards the diaphragm (LN station 112).
- 6.
Identify and ligate the thoracic duct at the proximal resection margin and above the diaphragm.
Specimen excision
- 7.
Ensure that the thoracic part of the specimen is circumferentially free, from the previously completed diaphragmatic mobilisation (performed during the abdominal phase) to at least the level of the aortic arch (LN stations 108, 110 and 111).
- 8.
Deliver the stomach into the right chest cavity ensuring that the gastric tube can reach the site of anastomosis without tension or torsion.
- 9.
Excise the specimen with suitable proximal and distal resection margins and send it to pathology as per the ROMIO trial protocol.
Anastomosis
- 10.
Perform an oesophago-gastrostomy using the preferred technique.
