Ivor Lewis esophagectomy
Anesthesia type



DLT / bronchial blocker

Lines and access

Large PIV, arterial line, NG tube


Standard, arterial line

Primary anesthetic considerations
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


  • 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


  • 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
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%)[1]


  1. Luketich, James D.; Pennathur, Arjun; Awais, Omar; Levy, Ryan M.; Keeley, Samuel; Shende, Manisha; Christie, Neil A.; Weksler, Benny; Landreneau, Rodney J.; Abbas, Ghulam; Schuchert, Matthew J. (2012-07). "Outcomes after minimally invasive esophagectomy: review of over 1000 patients". Annals of Surgery. 256 (1): 95–103. doi:10.1097/SLA.0b013e3182590603. ISSN 1528-1140. PMC 4103614. PMID 22668811. Check date values in: |date= (help)