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Arshava transhiatal retractor

last modified on: Mon, 05/18/2020 - 13:13

in Iowa Thoracic Surgery

Evgeny V. Arshava MD,  Ruchi Thanawala MD, John C. Keech, MD, Kalpaj R. Parekh, MBBS

Please direct questions and comments to Evgeny V. Arshava, MD evgeny-arshava@uiowa.edu

 

 

 

 

Visit also:

Esophagectomy for an Esophageal Cancer: General Considerations and Choice of Operation

Esophagectomy: Transhiatal—Laparotomy with Cervical Anastomosis

Cervical gastroesophageal anastomosis

Three-Field Esophagectomy (McKeown):  Laparotomy and right thoracotomy (thoracoscopy) with cervical anastomosis.

 

 

 

  • Transhiatal esophagectomy (THE) is favored by many surgeons for its simplicity, efficiency of the dissection, shorter operative time, avoidance of a thoracotomy associated morbidity, and decreased risk of mediastinitis from an anastomotic leak. Transhiatal esophagectomy (THE) is performed through combination of abdominal and cervical incisions. Visualization of the thoracic esophagus through the hiatus is limited compared to transthoracic approaches (Ivor Lewis and Three field McKeown). The mediastinal dissection of THE has been criticized by its opponents for blunt nature limited exposure, and lack of controlled hemostasis. Lower lymph node counts after THE have been reported as compared to transthoracic resections. 

  • The operation was popularized by the immense contribution Dr. Mark Orringer.  Large series demonstrated that the operation can be done efficiently with minimal blood loss and sound oncologic principles in experienced hands.  At the University of Iowa, transhiatal esophagectomy is the preferred approach for distal esophageal and gastroesophageal junction carcinomas.  The median lymph node count in our institution is 17. Postoperatively, patients are admitted to the regular surgical floor, with a typical length of stay of 5 to 7 days.

  • The mediastinal dissection was classically performed mostly “bluntly” and “blindly” by digital feel.  Dr. Orringer emphasized that as experience is gained with the transhiatal approach, less of the dissection of the distal half of the esophagus is done “bluntly” and suggested the use of a narrow deep Deaver retractor for the divisions of the lateral esophageal attachments and hemostasis.  Dr. Chernousov described the use of an angled illuminated retractor during esophageal dissection after a wide division of the diaphragm towards the central tendon.

  • Usually the posterior mediastinum is exposed using a Deaver retractor. Due to its shape and relatively flexibility, a Deaver retractor does not provide optimal exposure and stability of the retraction, especially in obese patients. The orientation of the Deaver handle requires a nearly vertical axis of retraction which can be uncomfortable and ineffective over prolonged retraction periods.

 

                   Deaver retractor                                                                Arshava Transhiatal Retractor

  Deaver retractor provides very limited visualization of the mediastinum during transhiatal esophagectomyArshava transhiatal retractor designed for comfortable retraction and improved visualization in the posterior mediastinum during esophagectomy

 

 

  • The Arshava Transhiatal Retractor (ATR) was developed and built as a dedicated transhiatal retractor to improve the exposure during mediastinal dissection. ATR has an elongated C-shaped blade. The open “mouth” of the blade is designed to naturally accommodate the shape of the diaphragm and heart and through the diaphragmatic hiatus. The blade is sufficiently rigid to ensure sustained, stable retraction. The ergonomic handle is oriented approximately 45 degrees away from “C” mouth allowing for optimal axis of retraction by the surgical assistant. 

Arshava illuminated  transhiatal retractorilluminated transhiatal retractor is used to facilitate exposure for mediastinal dissection during esophagectomy

 

  • At the University of Iowa, ATR is routinely used during all THEs and many of the MKEs.  This allows for dissection of the esophagus using a combination of suction tips, ringed forceps, and energy devices under direct vision up to the level of tracheal bifurcation. This dissection cannot reliably be performed safely when the dissection is carried without adequate visualization.

Right lateral esophageal attachments are divided during transhiatal esophagectomy under direct vision

 

  • Provided exposure allows a surgeon to resect or sample subcarinal and lower periesophageal lymph nodes under direct vision.

Subcarinal lymph nodes are resected during esophagectomy with limited uses of energy devices

 

  • Hemostasis is assured after completion of esophagectomy. 

exposure of the posterior mediastinum during esophagectomy  dissection and hemostasis check

 

  • Patient hemodynamics withstand mediastinal retraction better with the retractor than dissection with the hand through the hiatus. Placement of the surgeon’s hand in the mediastinum is only required for very limited duration of time, as most of the distal esophageal dissection has already been completed under direct vision.

  • The University of Iowa Research Foundation filed a patent application for the retractor. Illuminated ATR is currently manufactured by Precision Medical Devices (New Brunswick, New Jersey) with 38-mm-wide and 45-mm-wide blades.

  • Currently, we are prototyping a version of the retractor with embedded video and image capture functionality.

  • Arshava retractor_ design of a video transhiatal retractor to facilitate mediastinal dissection during transhiatal esophagectomy

 

  • We believe that adding a video feature may further enhance exposure and access to mediastinal lymph nodes.

 

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Suggested literature

 

Orringer M. Transhiatal esophagectomy. In: Deslauriers J, Meyerson SL, Patterson A, Cooper JD, eds. Pearson’s Thoracic and Esophageal Surgery. 3rd ed. London, UK: Churchill Livingstone; 2007:563-583.

 

Orringer MB, Marshall B, Chang AC, et al. Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg. 2007;246:363-372.

 

Chernousov AF, Andrianov VA, Domrachev SA, Bogopol’ski PM. The experience of 1100 esophagoplasties [in Russian]. Khirurgiia (Mosk). 1998;(6):21-25.

 

Espinoza-Mercado F et al. Does the Approach Matter? Comparing Survival in Robotic, Minimally Invasive, and Open Esophagectomies. Ann Thorac Surg. 2019 Feb;107(2):378–385.

 

Namm JP, Posner MC. Transhiatal Esophagectomy for Esophageal Cancer. J Laparoendosc Adv Surg Tech A. 2016 Oct;26(10):752-756. Epub 2016 Aug 22.

 

Yeung JC, Bains MS, Barbetta A, Nobel T, DeMeester SR, Louie BE, Orringer MB, Martin LW, Reddy RM, Schlottmann F, Molena D. How Many Nodes Need to be Removed to Make Esophagectomy an Adequate Cancer Operation, and Does the Number Change When a Patient has Chemoradiotherapy Before Surgery? Ann Surg Oncol. 2020 Apr;27(4):1227-1232. doi: 10.1245/s10434-019-07870-2. Epub 2019 Oct 11

 

Arshava EV, Arshava AE, Keech JC, Weigel RJ, Parekh KR. Illuminated Transhiatal Retractor for Mediastinal Dissection During Transhiatal Esophagectomy.  Ann Thorac Surg. 2020 Jan;109(1):e67-e69. doi: 10.1016/j.athoracsur.2019.07.076. Epub 2019 Sep 11

 

Weijs TJ, Goense L, van Rossum PSN, Meijer GJ, van Lier AL, Wessels FJ, Braat MN, Lips IM, Ruurda JP, Cuesta MA, van Hillegersberg R, Bleys RL. The peri-esophageal connective tissue layers and related compartments: visualization by histology and magnetic resonance imaging. J Anat. 2017 Feb;230(2):262-271. doi: 10.1111/joa.12552. Epub 2016 Sep 23.

 

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We would like to thank all the nurses and operative room technicians at the University of Iowa Hospitals and Clinics and the Iowa City VAMC for their dedication and expertise in the care of our patients.