The patient underwent intravenous-inhalation general anesthesia and double-lumen endotracheal intubation.
Throughout the laparoscopy-assisted abdominal surgery, the patient underwent two-lung ventilation and was placed in a supine position with five abdominal ports. The observation port was an 11-mm incision beside the umbilicus, and the other four ports were positioned at the incisions in the subcostal region of the left (5-mm port) and right midclavicular lines (5-mm port), and the incisions 2 cm superior to the umbilicus in the left (11-mm port) and right parasternal lines (5-mm port). The surgeon stood on the left side of the patient, which is the opposite of the standard position. Under the laparoscope, in accordance with preoperative imaging, the stomach was observed in the right hypochondriac region, the spleen to the right and rear of the stomach, and the liver on the left (Fig. 4a). The patient’s stomach was routinely mobilized, the abdominal lymph node was dissected, and the anastomosis was circularly embedded with the pedicled omentum flap. An assistant abdominal incision was subsequently made below the xiphoid process, and a gastric conduit of approximately 3.5 cm in diameter was created using a linear stapler (the Endo-GIA 60 − 4.1; Johnson & Johnson) outside the abdominal cavity. A jejunostomy was performed approximately 30 cm distal to the ligament of Treitz.
Before the two-port thoracoscopy-assisted thoracic surgery began, the patient was repositioned in a right prone position and underwent right single lung ventilation. The camera port was located at the eighth intercostal space on the posterior axillary line, and the operation port was positioned between the fourth and sixth intercostal space at the anterior axillary line. The surgeon stood on the abdominal side of the patient. Intraoperative observation revealed that the azygos vein and the three lobes lay in the left thoracic cavity (Fig. 4b). A tumor 5 cm in length with a maximum diameter of 3 cm was located in the middle and lower segment of the esophagus (from 2 cm above inferior pulmonary vein to 2 cm above the diaphragm) (Fig. 4c). The esophagus was mobilized at a site 4 cm superior to the azygos vein, and the pleura surrounding the esophagus at the anastomotic stoma and thoracic lymph nodes were systematically dissected.
The remaining steps in this surgery resembled that of surgery performed on situs solitus patients with esophageal cancer and consisted of purse-string suturing, the insertion of the anvil of the stapler, distal esophagectomy, and intrathoracic anastomosis of the esophageal stump and the tubular stomach. After anastomosis, a thoracoscopy was performed by inserting an endoscope into the gastric conduit to ensure the integrity of the anastomotic stoma and that it was not bleeding.
The overall operation time was 270 minutes, comprising laparoscopic operation time (100 minutes) and thoracoscopic operation time (170 minutes). Estimated blood loss was 150 mL. Throughout the procedure, systematic lymphadenectomies were conducted at levels 2R (right recurrent laryngeal nerve), 8 (middle-lower segment of the esophagus), 17 (left gastric artery), and at the lesser curvature of the stomach and pylorus. Postoperative pathology confirmed that a well to moderately differentiated squamous cell carcinoma had invaded the entire esophageal wall, including the serosa, with metastasis to the lymph nodes, including the 2R (1/8) and the pylorus (1/3). Finally, the patient was diagnosed with well to moderately differentiated esophageal carcinoma which was pathologically staged as T3N1M0, stage IIIB (UICC esophageal carcinoma pathological stage, 2017) [5]. There were no postoperative complications such as trachyphonia or other symptoms related to recurrent laryngeal nerve injury. After 20 days, the patient was discharged and advised to undergo adjuvant therapy in the oncology department. A video demonstrating the operation accompanies this article (Additional file 1).