Laparoscopic excision of a horseshoe-shaped leiomyoma of the lower esophagus

Esophageal leiomyomas are approximately 50 times less common than carcinomas, but they represent 80% of benign tumors of the lower esophagus. An esophageal leiomyoma can be enucleated safely and effectively through minimally invasive surgery. The laparoscopic approach is a conventional option for this kind of tumor (located near or at the esophagogastric (EG) junction). Laparoscopic transhiatal enucleation is a safe and feasible procedure. This video demonstrates all the technical details of a laparoscopic excision of a large horseshoe-shaped leiomyoma of the lower esophagus. A conventional port placement is used to approach the hiatal region.

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Laparoscopic excision of a horseshoe-shaped leiomyoma of the lower esophagus

Authors

B Dallemagne, J Marescaux

Abstract

Esophageal leiomyomas are approximately 50 times less common than carcinomas, but they represent 80% of benign tumors of the lower esophagus.
An esophageal leiomyoma can be enucleated safely and effectively through minimally invasive surgery. The laparoscopic approach is a conventional option for this kind of tumor (located near or at the esophagogastric (EG) junction). Laparoscopic transhiatal enucleation is a safe and feasible procedure. This video demonstrates all the technical details of a laparoscopic excision of a large horseshoe-shaped leiomyoma of the lower esophagus. A conventional port placement is used to approach the hiatal region.

Classification

complex cases

Keywords

Laparoscopic excision, horseshoe-shaped leiomyoma, lower esophagus

Media type

Surgical video

Duration

13'07''

Publication

2009-04

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E-publication

WeBSurg.com, Apr 2009;9(04).
URL: http://www.websurg.com/doi-vd01en2545.htm

Laparoscopic excision of a horseshoe-shaped leiomyoma of the lower esophagus

1. Clinical case presentation 00'17''

This is the case of a young patient presenting with GERD symptoms. During the diagnostic workup, the gastroscopy revealed a submucosal tumoral mass proximal to the cardioesophageal junction. Exploration was continued via an endoscopic ultrasound examination, which corroborated the presence of a mass about 6cm long. The radiography did not bring any new elements to light. The magnetic resonance imaging confirms the presence of a large mass situated just above the cardioesophageal junction. Statistically, the most common benign submucosal lesions of the esophagus are known to be leiomyomas. Conventional port placement is used to approach the hiatal region.

2. Exposure and mobilization of cardioesophageal junction 01'24''

Dissection starts with the exposure of the cardioesophageal junction in order to access the lower mediastinum and the esophageal lesion. The mediastinal approach performed is a typical one for GERD treatment: identification of the diaphragmatic crura, and progressive dissection of the lower mediastinum in order to identify the esophagus. As soon as we enter the mediastinum, we can observe that the esophagus occupies a large portion of the width of the hiatal orifice, which confirms the presence of a tumor at this level. The dissection therefore becomes slightly more difficult due to the widening of the esophagus. However, the different dissection planes are well respected. The objective is to mobilize the lower portion of the esophagus and place traction on the cardioesophageal junction. According to the preoperative imaging study, we know that the tumor is located just above the cardioesophageal junction. Therefore, a transhiatal approach can be attempted. It is obvious that for tumors situated on a more proximal segment of the esophagus, a transthoracic approach is recommended. It must be stressed that even with such large tumoral mass, this patient did not show any signs of patent dysphagia. This is also an argument in favor of the benign nature of the tumor. It must be remembered that the GIST or stromal tumors of the lower esophagus are rare and that leiomyomas represent 80% of benign tumors of the lower esophagus. Mobilization of the cardia turns out to be more difficult because of this important mass, measuring a little over 6cm as the endoscopy showed.

3. Posterior dissection 03'53''

The posterior dissection complies with the usual principles of structure identification, with identification of the posterior vagus nerve and of the left diaphragmatic crus. In this respect, the retroesophageal passage is made easier thanks to the extensive dissection of the left diaphragmatic crus’ base; this facilitates the identification of the retroesophageal passage when it is approached from right to left. The macroscopic aspect of the mass observed in this patient, along with the mobility of the lesion, allows to confirm reliably the diagnosis of leiomyoma. The objective of the treatment is to excise the leiomyoma, a submucosal tumor that does not invade the esophageal mucosa. The mobility of this tumor is clearly shown here and it seems to encircle the esophagus. It is a horseshoe-shaped tumor, almost annular. Some experts consider the resection of the esophagus in these types of tumors. In the present case, we also opt for resection.

4. Incision of longitudinal muscular layer of the esophagus 00'00''

The longitudinal muscular layer of the esophagus is superficially opened, which allows to approach the tumor and confirms its macroscopic aspect, typical of leiomyomas. The cleavage plane between the mucosa and the tumor must be dissected meticulously and progressively in order to avoid any injury to the esophageal mucosa.

5. Peroperative endoscopic control 06'08''

In this patient, given the lesion’s extent, we opt for an peroperative endoscopic control. This allows to control the presence of mucosal perforations. Some authors consider that the rigidification of the esophageal lumen, with a balloon catheter for instance, can improve the cleavage plane between the tumor and the mucosa. All manipulations should avoid grasping the tumor as it could rupture. We use traction threads, placed successively according to the mass’s freeing. Here, we can see the endoscope in the lower portion of the esophagus. This endoscope will control the position of the tumor and the preservation of the mucosa throughout the resection process.

6. Dissection of the tumor 08'00''

The dissection of the tumor itself can be performed with an ultrasonic scalpel as in done here. Some authors use the dissecting hook, although this increases the risk of thermal injury to the mucosa and subsequent perforation. Some experts use the cold scissors, but this can be the source of increased intraoperative bleeding and cause difficulties when identifying the cleavage plane. We can see here that the bulge of the mucosa induced by the endoscope’s insufflation may sometimes improve the identification of the cleavage plane. This tumor encircles the esophagus. However, it can be excised progressively by a simple myotomy performed at the anterior aspect of the esophagus. Some authors consider that a preoperative biopsy may make the dissection of the plane more difficult, and some surgical teams consider that a biopsy, generally performed under endoscopic control, is not useful and may increase the risk of intraoperative mucosal perforation. We can see here that the cleavage plane between the mucosa to the left and the tumor is clearly visible. The intraoperative control is very useful in such situations, especially when the tumor is entirely circumferential. Traction threads are positioned progressively so that the leiomyoma may be mobilized. As a rule, the myotomy is closed after extraction of the tumor in order to avoid the formation of pseudo-diverticulum. Some authors also consider that it is essential to combine an anti-reflux maneuver with division of the attachments of the gastro-esophageal junction, given the esophageal myotomy. In this patient, we did not perform a fundoplication since we felt that the myotomy zone was situated above the sphincter.

7. Closure of esophageal myotomy 11'08''

The myotomy’s suture is carried out with absorbable 3/0 or 4/0 material; here we use a running suture. This maneuver marks the end of the procedure in this patient.

8. Final endoscopic control 00'00''

The endoscopic control confirms the absence of mucosal perforations. No drainage is left in place. Following the stomach’s desufflation, the drain placed around the cardioesophageal junction is removed. The tumor is placed in an extraction bag and removed through the 10mm trocar site. It measures 15cm. It is shaped like a horseshoe and was positioned around the supracardial portion of the esophagus.

9. Post-procedure radiological control 13'02''

The morning after the procedure, a radiological contrast swallow ruled out any perforations and the patient was allowed to resume food intake. He was discharged on postoperative day two.