Exposure of the cervical esophagus

Tuesday, January 5, 2010

By

Christopher Komanapalli

James Cohen

Mithran Sukumar

This article describes a safe and effective way to mobilize the cervical esophagus paying special
attention to preservation of the recurrent laryngeal nerve.

Patient Selection

Exposure of the esophagus in the neck is required when an esophagectomy is being performed with a
cervical anastomosis. Open three field esophagectomy, transhiatal esophagectomy and minimally-
invasive three-field esophagectomy are examples. Exposure for a cervical esophagostomy, open repair
of a Zenker’s diverticulum, malignancies of the cervical esophagus and penetrating injuries of the neck
resulting in esophageal perforation are less frequent indications for cervical exposure. The preoperative
workup is for the underlying condition, as exposure of the cervical esophagus has minimal physiologic
impact on the patient.

The preferred side of exposure is the left, as the recurrent nerve is less likely to be injured than on the
right due to differences in position and course. The reason for this relates to the position of the left
recurrent laryngeal nerve, which is longer and more vertical in position than its counterpart on the right
because of its course around the aortic arch rather than the subclavian artery. This decreases the chance
of direct injury, as it stays in the tracheoesophageal groove for the majority of its course in the operative
field rather than traversing the space between the laryngotracheal complex and carotid sheath. The risk
of stretch injury is also decreased, as its length distributes any superior traction forces over a longer
segment of nerve.

A short neck, obesity and an enlarged thyroid gland are not contraindications to exposure of the
esophagus in the neck. Previous surgery, radiation, and tracheostomy make the dissection more
difficult but are not contraindications to exposing the esophagus in the neck.
Operative Steps

1. The incision is made horizontally beginning anteriorly at

the midline running over the anterior border of the
sternocleidomastoid (SCM) muscle and running to its
posterior border. It should be located just below level of
the cricoid cartilage or two fingerbreadths above the
head of the clavicle (Figure 1). Although a more vertical
incision along the anterior border of the SCM of Figure 1: Neck incision for exposure
equivalent length offers more exposure than a horizontal of the cervical esophagus.
incision, the cosmesis of the latter is preferable. In
situations where exposure is anticipated to be difficult, a
more vertical incision may be performed.

2. Short subplatysmal flaps are elevated superiorly and

inferiorly using cautery and blunt dissection to expose
the fascia, which is then incised along the anterior Figure 2: Fascial incision along
border of the SCM from the clavicle to the level of the anterior border of
thyroid cartilage notch. These flaps are retracted using sternocleidomastoid.
fish hook retractors that are clamped to the drapes
(Figure 2).
Figure 3: Relation between
A generous incision of this fascia and posterior mobilization of recurrent laryngeal nerve and
the SCM muscle bluntly allows maximal exposure and makes the inferior thyroid artery.
field as shallow as possible.

3. A self retaining weitlaner retractor is used to maintain the exposure. In the difficult neck it is
useful to incise or divide the sternal head of the SCM, which helps mobilize it inferiorly. The
SCM muscle is dissected posteriorly off the underlying sternohyoid muscle until the lateral
surface of the internal jugular vein is well seen. The anterior belly of the omohyoid muscle is
identified, which can be mobilized superiorly or divided as needed for exposure.

4. The middle layer of the deep cervical fascia is incised using tenotomy scissors vertically along
the anterior border of the internal jugular vein (taking the middle thyroid vein between ligatures
of 4-0 silk) and then more deeply (and slightly anteriorly) along the common carotid artery. The
carotid sheath can be retracted laterally with an army/navy or Richardson retractor (Figure 2).
Placing 2 Allis clamps on the lateral border of strap muscles allows the laryngotracheal complex
to be rotated anteriorly and medially, a maneuver which protects the recurrent nerve from
traction injury.

5. The middle layer of the deep cervical fascia, which surrounds the thyroid/laryngotracheal
complex, sends investments to the carotid sheath, which must be divided sharply to allow for
entry into the retropharyngeal /paraesophageal space. The inferior thyroid artery (Figure 3) is
ligated with 4-0 silk where it courses medially from behind the carotid artery. The distal
 branches of the inferior thyroid artery intertwine with the recurrent laryngeal nerve; that if the
artery is left intact, the traction on it produced by lateral traction on the carotid sheath and
medial retraction/rotation of the laryngotracheal complex may pull the nerve out of the groove
and increase the chance of injury to it.

If the patient has not been previously operated upon, the recurrent laryngeal nerve is not specifically
identified and dissected, as its course (on the left) in the paratracheal groove keeps it away from direct
injury if certain principles are adhered to (see below) and the surrounding tissues protect it from direct
trauma by retractors and to some degree from stretch injury. If the right side is chosen for exposure,
dissection is kept lateral, at the medial aspect of the common carotid artery. The nerve should be
identified as it traverses the gap between the carotid sheath and laryngotracheal complex (C7-T1) to go
around the subclavian artery (Figure 3).

6. The lateral aspect of the left thyroid lobe is grasped with two Babcock retractors and the
laryngotracheal complex is rotated anteriorly and medially to expose the lateral and posterior
aspect of the pharynx and esophagus. This direction of retraction is well tolerated. To prevent
stretch injury to the recurrent laryngeal nerve, superior retraction must be specifically avoided
(Figure 4). Although occasionally in the short/fat neck inferior sectioning of the sternohyoid /
sternothyroid muscles is necessary for superior displacement of the laryngotracheal complex
and esophageal exposure, in general preservation of these muscles helps guard against overly
aggressive superior retraction and stretch injury to the
recurrent laryngeal nerve.

7. Using the thyroid lobe as a handle on the laryngotracheal Figure 4: Incision of fascia over
complex, because of its tight attachment to it at Berry’s the esophagus.
ligament (connective tissue that attaches trachea to
thyroid), facilitates exposure without exposing the recurrent
laryngeal nerve to direct trauma by a retractor (Richardson Figure 5: Relation and course of
or army/navy) where the tip inevitably tends to migrate the recurrent laryngeal nerves in
towards the tracheoesophageal groove where the nerve the neck at high (a), mid (b) and
sits. Alternatively, a hook may be placed along the lateral low (c) levels.
edge of the thyroid cartilage and used to retract the
laryngotracheal complex medially in order to visualize the
region of the cricopharyngeal muscle and cervical Figure 6: Circumferential
esophagus. dissection of the esophagus.

8. With the above exposure, palpate the inferior cornu of the

thyroid cartilage, which serves to identify the level of the
Figure 7: Mobilization of the
cricoid cartilage and recurrent laryngeal nerve entry into the
esophagus.
larynx. Working 1-2 cm below this, the esophageal fascia is
incised sharply on the posterior-lateral aspect of the
 esophagus vertically downward for a distance of 2-3 cm (Figure 4). Alternatively, the
prevertebral plane may be dissected bluntly with a tonsil clamp or peanut dissector to expose
the posterior aspect of the esophagus.

Beginning the dissection higher on the esophagus and working on its posterior aspect (4-5 o’clock
position) ensures that the recurrent laryngeal nerve is anterior to the plane of dissection and will not be
directly injured. Subsequent dissection is done underneath this fascial layer, which protects the nerve
from direct injury as it is displaced off the surface of the esophagus. As one proceeds lower in the neck,
the left recurrent laryngeal nerve runs more anteriorly, decreasing the chance of direct injury if the
dissection is kept on the esophagus (Figure 5).

9. Once the subfascial plane is entered, dissection with a right angle clamp, the tip of which hugs
the muscular layer of the esophagus, is performed starting posteriorly and proceeding
anteriorly, working first behind and then anterior to the esophagus, developing a
circumferential plane around the esophagus (Figure 6). Gentle medial retraction on the trachea
can facilitate this, as it tends to rotate the esophagus to a more leftward position. Because the
dissection is done from left to right and is 3-4 cm below the cricoid cartilage, the right recurrent
laryngeal nerve is protected from direct injury, as at this level it has already traversed laterally
off the esophagus (Figure 5).

10. Using a right angle clamp, a 1” penrose drain is passed around the esophagus. Using this drain,
the esophagus is gently retracted laterally and superiorly, and a combination of sharp and blunt
(finger/peanut) dissection performed starting superiorly and proceeding inferiorly towards the
thoracic inlet to gradually mobilize and dissect the esophagus from the surrounding soft tissues
(Figure 7). Care must be taken to avoid injury to the posterior tracheal wall while doing this.

While performing this dissection a critical step is to provide specific downward counter traction on the
thyroid lobe to prevent stretch injury on the nerve, which can easily occur if, in the process of retracting
the esophagus superiorly, the laryngotracheal complex is pulled up as well. This circumferential
dissection of the esophagus can be carried inferiorly into the posterior superior mediastinum when
being performed for esophagectomy and superiorly as needed for other operations on the esophagus.
When the (thoracic) esophagus is brought up into the neck and transected, specific attention to this
downward traction must be maintained to prevent recurrent nerve injury.

Preference Card

 Blunt (fish hook) skin retractors

 Weitlaner retractor

 Bipolar cautery

 Tenotomy scissors

 Babcock retractors
  One inch Penrose drain

Tips & Pitfalls

 Use a headlight and loops to improve visualization.

 Divide inferior thyroid branches

 Rotate the laryngotracheal complex anteriorly and medially by using retraction on the thyroid or
strap muscles to maximize the chance to protect the recurrent laryngeal nerve.

Figure 1: Neck incision for exposure of the cervical esophagus.

Figure 2: Fascial incision along anterior border of sternocleidomastoid.
Figure 3: Relation between recurrent laryngeal nerve and inferior thyroid artery.
Figure 4: Incision of fascia over the esophagus.
Figure 5: Relation and course of the recurrent laryngeal nerves in the neck at high (a), mid (b) and low (c)
levels.
Figure 6: Circumferential dissection of the esophagus.
Figure 7: Mobilization of the esophagus.