New procedure for purse-string suture in thoracoscopic ... - Springer Link

Surg Endosc (2005) 19: 40–42 DOI: 10.1007/s00464-004-9138-9 Ó Springer Science+Business Media, Inc. 2004

New procedure for purse-string suture in thoracoscopic esophagectomy with intrathoracic anastomosis K. Misawa, T. Hachisuka, Y. Kuno, T. Mori, M. Shinohara, M. Miyauchi Department of Surgery, Yokkaichi Municipal Hospital, 2-2-37 Shibata, Yokkaichi City, 510-8567, Mie, Japan Received: 28 May 2003/Accepted: 24 June 2004/Online publication: 11 November 2004

Abstract Background: In endoscopic surgery, one of the greatest problems is the difficulty with the reconstructive procedure. This problem frequently makes operating times longer. The authors have performed thoracoscopic esophagectomy and intrathoracic esophagogastric anastomosis for reconstruction using a circular stapler for the esophageal cancer. Although the circular stapler is a useful device for gastrointestinal anastomosis, it was difficult to place a purse-string suture and to fixate the anvil into the proximal esophagus endoscopically. Methods: The authors devised a new procedure for the placement of the purse-string suture by using an EndoStitch device along with a new method to incise the esophageal wall and thereby facilitate fixation of the anvil. Results: The authors attempted this procedure for five patients. The anastomoses were performed successfully. Conclusions: The new procedure can make endoscopic intrathoracic anastomosis feasible and safe. In addition, this procedure can be applied widely to other endoscopic reconstructions. Key words: Esophageal cancer — Thoracoscopic esophagectomy — Intrathoracic esophagogastric anastomosis — Purse-string suture — Endo-Stitch

Thoracoscopic esophagectomy has been widely performed for cancer of the esophagus [2–5]. Since June 1997, we have performed thoracoscopic esophagectomy and intrathoracic esophagogastric anastomosis for reconstruction using a circular stapler for cancer of the middle and lower thoracic esophagus. In our procedure for intrathoracic anastomosis, a purse-string suture is placed endoscopically around the proximal esophagus. The anvil of a circular stapler then

Correspondence to: T. Hachisuka

is introduced into the proximal esophagus, and the purse-string suture is tied. Next, the esophagogastric anastomosis is created using the circular stapler. In the past, we used a Purstring instrument (U.S. Surgical, Norwalk, CT, USA), an endoscopic purse-string instrument (Ethicon Endo-Surgery, Cincinnati, OH, USA), or an endoscopic needleholder and a strung needle for the placement of the intrathoracic purse-string suture. However, the techniques using these instruments at the apex of the thoracic cavity were not easy, and this problem frequently made operating time long. Recently, we devised a new procedure for the placement of the intrathoracic purse-string suture by using the Endo-Stitch device along with a new method to incise the esophageal wall and thereby facilitate fixation of the anvil. We describe our surgical procedure.

Materials and methods The Endo-Stitch device (U.S. Surgical) is shown in Fig. 1. This singleuse 10-mm endoscopic suturing device has two jaws and a doubleended straight needle. The needle is threaded in the middle with a suture, and held in one jaw. It can be passed to the other jaw by closing the handles and flipping the toggle levers. It can place interrupted or running stitches in soft tissues. Almost all manipulation of this device can be performed easily with one hand [1, 6]. The patient is positioned on the operating table in a left lateral position, with his or her right arm held in a raised position. A minithoracotomy 5-cm long is made on the fifth intercostal space of the right chest wall. Then the first assistant inserts a tracheal and lung retractor through the minithoracotomy, and the right lung is flattened gently. Three Thoracoports (U.S. Surgical) are introduced. A port is inserted at the anterior axillary line at the sixth or seventh intercostal space for placement of a flexible electroendoscope (Olympus, Tokyo, Japan). The two other ports for the operating instruments are placed as follows: one at the posterior axillary line at the seventh intercostal space, and the other at the midaxillary line at the third intercostal space. The esophagus is mobilized thoracoscopically. The level of transection is decided, and the distal esophagus is tied with 2-0 silk string. The esophageal wall then is incised at the level of transection using ultrasonic shears, but not severed completely; one-sixth of the left-side wall is left. The proximal esophageal edges are grasped with two endoscopic Allis clamps, one inserted by the surgeon through the minithoracotomy, and the other inserted by the first assistant through the

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Fig. 3. Photo taken from d of Fig. 2.

Fig. 1. Endo-Stitch device.

Fig. 2. Purse-string suture placed around the proximal esophageal rim using the Endo-Stitch device. a Endo-Stitch device. b Endoscopic Allis clamps. c Proximal esophagus. d Flexible electroendoscope.

port at the third intercostal space. The stump then is opened triangularly to facilitate suturing. Next, the Endo-Stitch device is introduced through the port at the seventh intercostal space. The posterior wall of the proximal esophagus is placed between the jaws; the jaws are closed; and the needle is passed through the wall from the outside to the inside. The jaws then are opened, and the suture is pulled through the wall, leaving a tail. Through the next suturing point, placed about 4 mm away in the clockwise direction, the second stitch is made from the inside to the

Fig. 4. The anvil of a 25-mm circular stapler is introduced into the proximal esophagus A, and the purse-string suture is tied B. a Anvil. b Anvil-shaft clamp. c Knot pusher.

outside. Approximately 10 stitches are placed around the proximal esophageal rim using the same steps (Figs. 2 and 3). It is easy to run the suture inside the wall at the point of the two clamps and the connected wall. When the suture runs around the esophageal rim and returns to the starting point, the last stitch is placed through the wall from the inside to the outside. The tails of the suture are then pulled out from the minithoracotomy. Next, the anvil of a 25-mm circular stapler is introduced into the proximal esophagus, and the purse-string suture is tied (Fig. 4). Then the esophageal wall is cut completely using ultrasonic shears. To prevent the esophageal edges from falling out of the purse-string suture

42 and sticking out from the circular staple line, an Endoloop ligature (Ethicon Endo-Surgery) is placed over the purse-string suture, and the fixation of the anvil is completed. After the excision of the distal esophagus with the lesion, the gastric tube, which is already on the ready for open or laparoscopic surgery, is delivered into the thoracic cavity. The proximal end of the gastric tube is pulled out of the minithoracotomy. The circular stapler without the anvil then is introduced into the gastrotomy incision, and the posterior wall of the gastric tube is pierced by a center rod. The circular stapler is introduced into the thoracic cavity with the gastric tube. The anvil then is mated with the center rod of the circular stapler; the stapler is closed and fired; and the anastomosis is created at the apex of the thoracic cavity. After completion of the esophagogastric anastomosis, the gastrotomy is closed thoracoscopically using an endolinear stapler. Hemostasis is ensured, and two chest drains are inserted through the ports. The lung is reinflated, and all the incisions are closed.

Results We have attempted this procedure in five patients with cancer of the middle and lower thoracic esophagus. In the latter cases, the fixations of the anvil were completed in about 20 min. Within this series, the anastomoses were performed successfully without conversion to open surgery or intraoperative complications. There was neither leakage nor any postoperative complications with this procedure. Discussion In the past decade, the development of endoscopic surgery has made almost all kinds of operation possible endoscopically. Not only obliterating techniques, but also reconstructive techniques have become diversified. In the field of thoracoscopic and laparoscopic surgery, the most frequent reconstructive technique is anastomosis of the gastrointestinal tract. Also, there are many techniques such as manual suturing of the intestines (which are pulled out of a small incision), functional end-to-end anastomosis using linear staplers, and endoscopic suturing using a needleholder. Each technique, however, has some problems such as the length of the small incision, the technical difficulties, and the extension of the operating time. A circular stapler is one of the most useful devices for gastrointestinal anastomosis in open and endoscopic surgery. It enables circular anastomosis, which is ideal for safe, secure gastrointestinal anastomosis. Therefore, we have used the circular stapler for intrathoracic esophagogastric anastomosis in thoracoscopic esophagectomy. The anastomosis was performed with little difficulty, although it was difficult to place a purse-string suture and to fixate the anvil into the distal esophagus at the apex of the thoracic cavity. For the placement of a purse-string suture, several devices and techniques have been used. The Purstring 45 instrument (U.S. Surgical) is the device that can most easily place the purse-string suture around the intestinal tract. However, we need at least an 8-cm extended incision to introduce it into the thoracic cavity. Thus, it cannot be introduced through a 5-cm thoracotomy in our thoracoscopic esophagectomy. The endoscopic purse-string instrument (Ethicon Endo-Surgery) has two serrated jaws, which are placed

around the esophagus. Next, a suture fitted with two straight needles is passed through the jaws. Then the purse-string suture is completed around the esophagus. It can be introduced even through a small incision that is not large enough for the Purstring 45 device. However, it is not easy to pass the 5-cm needles through the jaws in the thoracic cavity because of the limited space. Moreover, as the location of the anastomosis is higher, it becomes more difficult to place the jaws of the purse-string instrument at right angles to the esophagus. The manual suturing technique with an endoscopic needleholder and a threaded needle is the basic endoscopic technique. However, it is widely known that the translation of the open suturing technique into endoscopic methods often is difficult, and that this technique requires surgical experience and a long operating time. Use of the Endo-Stitch device can reduce the operating time required for placement of the purse-string suture. This procedure, simple and easy to perform, makes a complete purse-string suture regardless of the location of the anastomosis. Therefore, it can contribute to a stable esophagogastric anastomosis using a circular stapler. In addition, our method of incising an esophageal wall can facilitate the fixation of the anvil for the anastomosis even more. In the past, we severed the esophagus and grasped the esophageal stump with at least three clamps. But because there were too many instruments in the operating area, they became both visual and manipulative obstacles. With this new method, the connected esophageal wall is substituted for one of the clamps and can open the stump with two clamps to facilitate suturing and introduction of an anvil. One of the greatest problems with endoscopic surgery is the difficulty with reconstructive procedure. However, our new procedure can make the intrathoracic anastomosis using a circular stapler feasible and safe. In addition, this procedure can be applied widely not only to esophagogastric anastomosis in a thoracoscopic esophagectomy, but also to some other endoscopic reconstructions such as esophagojejunal anastomosis in a total gastrectomy and gastroduodenal anastomosis in distal gastrectomy.

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