Conventional surgeries for cancer of esophagus are often associated with significant morbidity and mortality. With the introduction of laparoscopy in surgical oncology, its role in management of esophageal cancer is increasing. Minimally invasive esophagectomy represents significant technologic advances in laparoscopic and thoracoscopic surgery over the past decade. These procedures are technically challenging and are currently performed in only a few medical centers in the world. Our protocol for carcinoma esophagus is as follows; thoracolaparoscopic esophagectomy for middle third lesions, laparoscopic transhiatal esophagectomy for lower third and laparoscopic esophagogastrectomy with intrathoracic anastomosis for patients harboring adenocarcinoma at cardia. This video demonstrates the technique of thoracolaparoscopic esophagectomy for middle third lesions of esophagus. The combined thoracoscopic and laparoscopic esophagectomy is the treatment of choice for resectable squamous cell carcinoma of the middle third esophagus.

Thoraco-Iaparoscopic esophagectomy is done in three stages with change of position during the surgery. Thoracoscopic part of the procedure is done in prone position with single lumen endotracheal tube and the abdominal and cervical part of procedure is done in semilithotomy position with reverse Trendelenberg. Pnuemothorax is created by Veress needle technique and the foHowing ports are placed; 5th intercostal space below the inferior angle of the scapula for camera: 10 mm, and 2 5mm ports on either side of the camera as shown in the video. The pnuemothorax is maintained with low pressure insufflation of 6 mm Hg. After assessing the lesion, the mediastinal pleura is incised and azyzos vein ligated after isolation. The incision on the mediastinal pleura is extended over the whole length and complete dissection is performed from the thoracic inlet to the esophagogastric junction. The retraction of the esophagus is performed with umbilical tape as demonstrated in the video. After completion of moblisation the lungs are inflated after inserting an intercostal drain. The patient's position is changed to semilithotomy for laparoscopic mobilization. After creation of pneumoperitoneum and the five ports, the gastric mobilization is performed. The lesser omentum is incised, the left gastric artery and vein dissected, ligated with silk and divided. All lymphofatty tissue around the branches of the celiac artey is completely removed. Gastrocolic omentum is divided between the stomach and transverse colon. This completes the mobilization of the stomach. The division of the esophagus is performed at the neck and a Ryle's tube is tied to the divided end. The specimen is pulled into the peritoneal cavity along with the Ryle's tube and exteriorized through a minilaparotomy and a protective sheath. The resection is done after adequate distal margin. The stomach tube is performed either by hand sewn technique or by linear staplers and the tube is replaced inside after tying the Ryle's tube to the proximal end. Pyloromyotomy is routinely performed. The minilaparotomy is closed and pneumoperitoneum recreated. The stomach tube is pulled into the mediastinum by traction on the Ryle's tube avoiding any torsion during the process. The esophagogastric anastomosis is performed in single layer by hand-sewn method in end-to end fashion or using linear stapler in side-to-side fashion. Neck wound is closed in layers after placing a corrugated drain. The ports are closed after deflation. From 1995 to 2004, we have performed minimally invasive esophagectomies in 130 patients of esophageal cancer. Indications for surgery was squamous cell carcinoma ( n= 110) and adenocarcinoma ( n=20). Squamous cell carcinoma was found in middle third (n=72) and lower third (n=38) of esophagus while adenocarcinoma was found at lower end of esophagus and cardia only. The results will be discussed following the video presentation. Thoraco-Iaparoscopic esophagectomy is a safe and feasbible option for cancers of the middle third and is likely to become the favoured procedure in the near future.