This can be successfully performed thoracoscopically although it is the most difficult and technically challenging procedure thus described. A truncal vago-tomy may also be performed thoracoscopically using similar techniques. The critical concept is that the esophagus must be accurately and easily identified. This is best accomplished by insertion of an upper GI flexible endoscope to permit more rapid visualization of the esophagus thoracoscopically. We have used an esophagoscope with a flashing light which can be transmitted through the esophagus to permit even easier identification. A second major function of esophagoscopy is to identify at what point the myotomy is complete. Once the esophagomyotomy is carried down onto the surface of the stomach (where classically the longitudinal venous plexus becomes transverse), then transection of the lower esophageal sphincter has occurred. At this point on endoscopy, one will see a sudden relaxation which yields evidence that the esophagomyotomy is complete.

Besides the thoracoscope port, the other access ports include a lung retractor, scissors attached to an electrocautery for the esophagomyotomy, a separate retractor for the diaphragm and a grasper to pick up the esophagus.

The thoracoscope is inserted in the fourth intercostal space of the posterior axillary line and directed down toward the diaphragm and lower esophagus. It is important to note that the video screen should be positioned at the feet of the patient, since the surgeon will be standing near the head of the patient. The lung is deflated and the patient placed with the head down to permit better retraction of the lower lobe cephalad. A lung retractor is placed in the fourth intercostal space in the anterior axillary line to retract the lower lobe anteriorly and superiorly. Another retractor is placed in the seventh intercostal space in the posterior axillary line to push the diaphragm inferiorly. A grasper and scissors are placed in the sixth to eighth intercostal space more posteriorly to manipulate and myotomize the esophagus. The thoracoscopic camera should be placed through the seventh intercostal space quite posteriorly to permit best visualization of the esophagus. The port positions are shown in Figure 25.4.

Outstanding results have been achieved using thoracoscopic technique for esophagomyotomy. We have successfully performed the procedure at Harbor. The

Fig 25.4. Video thoraco-scopic esophagomyotomy. The thoracoscope is placed into the seventh interspace at the midaxillary line. The grasper, scissors and retractors are placed via other ports. Esophagoscopy from above helps visualize the esophagus (see text). Reprinted with permission from Am Thoracic Surg 1992; 54:800-807.

pain and disability of a thoracotomy is one reason why the less invasive but less effective pneumatic dilatation is so frequently used as the initial management. Pneumatic dilatation even in the best of hands has only an 80% initial success rate and has its own complications, including esophageal perforation. The advantage of this video guided approach is that it avoids the more invasive thoracotomy.

It should also be noted that esophagomyotomy alone remains controversial as there are some groups that routinely perform fundoplication with their esophagomyotomies to prevent gastroesophageal reflux. Most groups, however, feel that fundoplication is not necessary as gastroesophageal reflux should not be a problem if the lower extent of the esophagomyotomy is limited to the lower esophageal sphincter. The myotomy should only extend onto the surface of the stomach to the extent as determined by the endoscopist seeing a sudden relaxation of the lower esophageal sphincter. Laparoscopic esophagomyotomy without fundoplication is conceptually sound.

Suggested Reading

1. Landreneau RJ, Mack MJ, Hazelrigg SR, Dowling RD, Acuff TE, Magee MJ, Ferson PF. Video-assisted thoracic surgery: basic technical concepts and intercostal approach strategies. Ann Thorac Surg 1992; 54:800-807.

2. Miller DL, Allen MS, Deschamps C et al. Video-assisted thoracic surgical rocedure: management of a solitary pulmonary nodule. Mayo Clin Proc 1992; 67:462-464.

3. Pellegrini C, Wetter LA, Patti M, Leichter R, Mussan G, Mori T, Bernstein G, Way L. Thoracoscopic esophagomyotomy. Ann Surg 1992; 216:291-299.

Acanthosis nigricans 186 Achalasia 235, 238-240 Acidosis, 15ACT (activated clotting time) 167 ACTH 26

Acute myocardial infarction 57, 65, 67, 69

Acute tubular necrosis (ATN) 162 Adenoid cystic carcinoma 181 Afterload 82, 88, 101, 148, 155, 156 Air embolus 29

Airway obstruction 247, 248, 278, 281, 282 Albright syndrome 219 Albumin 80, 155, 157, 165 Allograft aortic root replacement 103, 106

Alpha stat method 28

Amicar 26, 167

Amrinone 27, 63

Anemia 149, 163

Angioplasty 57-60

coronary artery bypass 24, 56-61, 69-72

Annular ectasia of the aortic valve 75,

77 Aorta ascending replacement with aortic valve 77 Aortic allograft 102 Aortic dissection 109, 111-118, 120, 123

repair 109-111, 118, 119, 122, 123, 125, 126, 129 Aortic insufficiency 9, 14, 15, 23, 25, 75-77, 82, 101, 106, 112, 114, 116, 120, 123, 126 Aortic mitral annulus 2, 5 Aortic rupture, traumatic 129, 251 Aortic stenosis 9, 14, 15, 75-77, 133 Aortic valve 1-5, 6, 9, 14, 22-24 anatomy 75, 76

endocarditis 75, 82, 92, 101-103 Aortic valve replacement combined mitral valve replacement 100

pulmonary autograft 102, 104-107 technique 77, 79 Apical bleb resection 291, 293, 294 Aprotinin 26, 27 Arterial blood gas 188, 189 Arterial filters 29 Arterial line 77, 153 Asbestos 223

Aspiration 187, 192, 235, 236 Aspirin 61

Atrial flutter/fibrillation 159 Atrial line 153

Atrial premature contractions 159 Atrioventricular septum 87 Atropine 155, 160 Autologous transfusion 27 AV node 2, 4, 5, 8

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