Ivor Lewis esophagectomy

Ivor Lewis esophagectomy

Anesthesia type	General
Airway	DLT / bronchial blocker
Lines and access	Large PIV, arterial line, NG tube
Monitors	Standard, arterial line
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
Article quality
Editor rating	In development
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The Ivor-Lewis transthoracic esophagectomy can be used to resect cancers in the lower third of the esophagus. It is not the optimal approach for cancers located in the middle third because of the limited proximal margin that can be achieved. This procedure combines a laparotomy with a right thoracotomy and an intrathoracic esophagogastric anastomosis. This approach permits direct visualization of the thoracic esophagus and allows the surgeon to perform a full thoracic lymphadenectomy.

Preoperative management

Operating room setup

• Arterial line +/- flowtrack (ideally on left arm)
• Fluid warmer
• Double-lumen tube (left) / bronchial blocker with SLT

Regional and neuraxial techniques

• Thoracic epidural (T7-8 commonly)

Intraoperative management

Monitoring and access

• Invasive hemodynamic monitoring
• Large bore IV access

Induction and airway management

• May consider RSI if high-aspiration risk due to esophageal tumor obstructing food passage
• Left sided double lumen tube or single lumen ETT with bronchial blocker for one lung ventilation
• NGT placed after airway management

Positioning

• Start in supine position if EGD is used at the beginning of the case
• Patient will be later positioned to left lateral decubitus for the thoracic portion of the resection

Maintenance and surgical considerations

Abdominal Dissection

• Pt is placed supine and peritoneal cavity is examined for metastatic disease
• Lower portion of the stomach is mobilized
• Gastric conduit formed
• A cervical anastomosis is performed and esophagus and stomach returned to mediastinum

Postoperative management

Disposition

• Post-op ICU

Pain management

• Epidural

Potential complications

1. Anastomotic leak
2. Vocal cord paresis
3. Recurrent laryngeal nerve injury
4. Morbidity requiring re-operation
5. Mortality

Procedure variants

	Open	Laparoscopic	Robotic
Unique considerations
Position		Supine followed by left lateral decubitus
Surgical time
EBL
Postoperative disposition	ICU	ICU or ERAS	ICU or ERAS
Pain management	Thoracic Epidural	Thoracic Epidural	Thoracic Epidural
Potential complications		Anastamotic leak (4.3%) Vocal cord paresis (0.9%) Mortality (1.68%)