Simplifying minimally invasive transhiatal esophagectomy with the inversion approach: Lessons learned from the first 20 cases

Hypothesis: The laparoscopic transhiatal esophagectomy can be simplified and performed safely and effectively by using a novel esophageal inversion technique. Design: Case series describing technique, initial experience, and learning curve with laparoscopic inversion esophagectomy. Setting: Tertiary care university hospital and veteran's hospital. Patients: Twenty consecutive patients with highgrade dysplasia (n = 16) and esophageal adenocarcinoma (n = 4). Intervention: Laparoscopic inversion esophagectomy, a totally laparoscopic approach to transhiatal esophagectomy that incorporates distal to proximal inversion to improve mediastinal exposure and ease of dissection. Main Outcome Measures: Perioperative end points and complications, compared between the first and second groups of 10 patients. Results: There were 19 men and 1 woman. Median operative time was 448 minutes. Median blood loss was 175 cm³. Median intensive care unit stay was 4 days, and median total hospital stay was 9 days. Overall anastomotic leak rate was 20%. Five patients developed an anastomotic stricture, all successfully managed with endoscopic dilation. There were 2 recurrent laryngeal nerve injuries, which resolved. There was no intraoperative or 30-day mortality. Between the first 10 consecutive cases and last 10 procedures, the incidence of anastomotic leak and stricture formation decreased from 30% to 10% and 40% to 10%, respectively. During this period, the number of lymph nodes harvested increased 9-fold, and duration of intensive care unit stay decreased from 8.00 to 2.50 days. Conclusions: Laparoscopic inversion esophagectomy is a safe procedure. The learning curve for the inversion approach is approximately 10 operations in the hands of esophageal surgeons with advanced laparoscopic expertise.