Total Minimally Invasive Ivor Lewis Esophagectomy (TMIE)

Total minimally invasive Ivor Lewis esophagectomy (TMIE) is one of the most advanced surgical procedure for treating esophageal cancer. This two-field esophagectomy involves both abdominal and right thoracic approaches. The abdominal stage (laparoscopy) focuses on critical steps such as complete stomach mobilization (gastrolysis), pyloromyotomy, extended abdominal lymphadenectomy, and gastric conduit creation. Additionally, it involves the use of intraoperative fluorescence-mediated angiography with indocyanine green (ICG) dye to assess gastric perfusion before creating the conduit. The procedure also emphasizes the importance of the feeding jejunostomy placement (to provide a feeding backup in high-risk patients) and peritoneal colpopexy (to prevent diaphragmatic hernia). The right thoracoscopic stage includes azygos vein ligation, esophageal dissection, thoracic duct ligation, esophagectomy, and lymphadenectomy, ensuring a radical resection of the tumor and related lymph nodes. Subsequently, preparation for anastomosis is performed, followed by mini-thoracotomy for specimen extraction and esophagogastric anastomosis using circular staplers. A paravertebral catheter is placed for postoperative pain management. Additionally, this technique highlights the use of US-guided indocyanine green injection into inguinal lymph nodes for thoracic duct identification during the right thoracoscopic stage. This is an extensive overview of the surgical technique, including patient positioning, trocar placement, and surgical instruments used. This detailed description serves as a valuable resource for surgeons and medical professionals involved in esophagectomy procedures.