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Minimally invasive esophagectomy: Preservation of arch of Azygos vein in prone position

1 Department of Surgical Oncology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
2 Department of Surgical Oncology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India
3 Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
4 Department of Anaethesiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
5 Department of Pathology and Lab Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
6 Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission14-Oct-2020
Date of Acceptance12-Jan-2021
Date of Web Publication08-Mar-2021

Correspondence Address:
Madhabananda Kar,
Department of Surgical Oncology, All India Institute of Medical Sciences, Sijua, Patrapada, Bhubaneswar - 751 019, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.JMAS_267_20


Minimally invasive esophagectomy (MIE) for oesophageal cancer has gained wide popularity in recent years due to its improved morbidity and mortality outcomes. We describe our modified technique of MIE in prone position with preservation of the arch of azygos vein. In our experience with 14 patients, the mean operative duration was 378 min (standard deviation [SD] 378 ± 59 min) and the mean blood loss was 390 ml (SD 390 ± 142 ml). The mean lymph node count was 28 (range 17–54). The Visick score was I in 12 (85.7%) patients and II in 2 (14.3%) patients at follow-up. The preservation of azygos vein arch is a technically feasible procedure and may be associated with a better quality of life outcome.

Keywords: Azygos vein, esophagectomy, minimally invasive

How to cite this URL:
Kar M, Imaduddin M, Muduly DK, Sultania M, Houghton T, Panigrahi MK, Misra S, Patra S, Mohakud S. Minimally invasive esophagectomy: Preservation of arch of Azygos vein in prone position. J Min Access Surg [Epub ahead of print] [cited 2021 Apr 20]. Available from:

  Introduction Top

Minimally invasive esophagectomy (MIE) in oesophageal cancer management has become the standard of care in the last decade.[1],[2] Several authors have described their techniques in lateral, prone or lateral-prone position and usually describe the crucial step of securing and ligating the arch of the azygos vein. We here describe our MIE technique with thoracic mobilisation of the oesophagus in the prone position and a particular focus on preserving azygos vein arch.

  Operative Technique Top

Anaesthesia and position

Intubation is done using a left-sided double-lumen endotracheal tube for the right lung collapse. Patients are placed in the prone position with arms abducted above 120° for the thoracoscopic phase. The surgeon stands on the right side of the patient with the camera assistant to the surgeon's left. Laparoscopic cart is positioned at the left shoulder of the patient.

Port position

Three thoracoports are placed – One 10 mm camera port in seventh intercostal space along the posterior axillary line and two 5 mm working ports in fourth and eighth intercostal space in line with the angle of scapula. A 30° camera scope is used for the procedure.

Oesophageal mobilisation

A general survey is performed to assess the mobility of the tumour and extension to surrounding structures. The collapsed right lung falls due to gravity in the prone position and provides good ergonomics with a clear view of the entire length of the oesophagus [Figure 1]. Dissection is started below the level of carina and proceeded up to diaphragmatic hiatus. The oesophagus is dissected free from the posterior chest wall and descending thoracic aorta keeping the fatty tissue containing lymph nodes on oesophageal side. Prone position assists in this dissection as the oesophagus drops down due to gravity and this, in turn, avoids an additional port for looping and retracting the oesophagus. Once the oesophagus's infracarinal portion is mobilised, dissection proceeds superiorly until the azygos vein arch is reached. The mediastinal pleura over the azygos vein is left intact, and the oesophagus is mobilised superior to the azygos vein up to the thoracic inlet.

As the oesophagus is approached above the azygos vein level without dividing the azygos vein, it may be difficult to identify the oesophagus in this location. The anaesthetist is requested to pass a flexible bronchoscope into the oesophagus, light of which can help in identifying the oesophagus [Figure 2]. Oesophagus is then pulled laterally using a grasper and dissection is continued medially dissecting it free from the superior vena cava. At this stage, vagal trunks are identified and divided. The attention is now directed towards the arch of azygos vein. Mediastinal pleura over the arch is held using a grasper and pulled laterally to provide traction. A plane is created between the azygos vein and oesophagus baring the anterior aspect of azygos vein free of all lymphatic tissue with a combination of blunt and sharp dissection. The right bronchial artery can be identified during this step and preserved [Figure 3].
Figure 1: Thoracoscopic view of oesophagus in prone position (A: Arch of azygos vein, E: Esophagus)

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Figure 2: Utilisation of light source for identification of oesophagus (A: Arch of azygos vein)

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Figure 3: Arch of azygos vein dissected free of oesophagus (A: Arch of azygos vein, B: Bronchial artery)

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Oesophagus is then dissected free from membranous portion of trachea. Trachea is at risk of injury during this step, which can be avoided by careful retraction of oesophagus and co-ordinating dissection with expiratory collapse of trachea. Care should be taken to include fatty tissue from the infracarinal space avoiding injury to pericardium and the right and left main bronchi [Figure 4]. The left side of oesophagus is now addressed. The azygos vein arch may form a hurdle to access the left side of oesophagus. However, proper retraction of the oesophagus laterally and posteriorly provides adequate access to the left side. The oesophagus can be dissected free of the left-sided pleura, thereby completing the thoracic mobilisation of oesophagus en bloc with surrounding lymphatic tissue [Figure 5].
Figure 4: Oesophagus dissected free from carina and trachea with lymph nodal clearance (T: Trachea, C: Carina)

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Figure 5: Mobilisation of oesophagus above the level of azygos vein and access to the left side of oesophagus (A: Arch of azygos vein, E: Oesophagus)

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Gastric mobilisation and specimen removal

Gastric mobilisation is done using standard technique. Cervical oesophagus is mobilised, transected and specimen delivered by a minilaparotomy incision after forming a gastric conduit.


Pyloroplasty is done by Heineke–Mikulicz method. Gastric conduit is pulled up and oesophagogastric anastomosis performed.

  Benefits Top

We performed minimally invasive azygous vein arch preserving esophagectomy in 14 patients. The procedure was uneventful and did not require conversion to an open method. The median age was 61.5 years (range 42–78 years) with male to female ratio of 11:3. The mean operative duration of the entire procedure was 378 min (standard deviation [SD] 378 ± 59 min) and mean blood loss was 390 ml (SD 390 ± 142 ml). Median ICU stay was 1 day, and the median hospital stay was 9.5 days (range 5–21 days). Mean number of lymph nodes harvested was 28 (range 17–54). In the postoperative quality of life assessment, 12 patients (85.7%) showed a Visick score of I and two patients (14.3%) had a Visick score of II.

MIE is now considered the standard approach and is associated with a significant decrease in morbidity and mortality, faster recovery and shorter hospital stays.[2] Thoracoscopic phase of the procedure can be done in either left lateral or prone positions with similar postoperative outcomes. Prone position decreases lung injury chances due to retraction as the lung collapses and falls due to gravity. It gives excellent exposure to the operative field and decreases chances of bronchial and tracheal injuries. Better ergonomics help shorten the operative duration, which, in turn, reflects better postoperative respiratory outcomes.

Azygos vein is routinely preserved in transhiatal esophagectomy, but the arch is routinely ligated in MIE. Theoretically, leaving the arch intact helps maintain the gastric conduit in the posterior mediastinum and by providing a slight constricting effect, it helps prevent reflux, apart from maintaining the natural venous system. In contrast, it can compromise lymph nodal clearance and influence outcomes. In our series of 14 patients, the mean number of lymph nodes harvested was 28 which was comparable to the nodes harvested in series where the arch was divided, 10.3 by Nguyen et al., 20 by Luketich et al. and 18 by Palanivelu et al.[2],[3],[4] We used the Visick score[5] for quality of life assessment and 85.7% of patients reported a score of I. This was similar to the outcome, 89.23% with Visick score I, reported by Palanivelu et al.[4]

In conclusion, we believe that preserving the azygos vein arch is a technically feasible procedure and may be associated with a better quality of life outcome without compromising the oncological outcome.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Nguyen NT, Roberts P, Follette DM, Rivers R, Wolfe BM. Thoracoscopic and laparoscopic esophagectomy for benign and malignant disease: Lessons learned from 46 consecutive procedures. J Am Coll Surg 2003;197:902-13.  Back to cited text no. 1
Nguyen NT, Follette DM, Wolfe BM, Schneider PD, Roberts P, Goodnight JE Jr., Comparison of minimally invasive esophagectomy with transthoracic and transhiatal esophagectomy. Arch Surg 2000;135:920-5.  Back to cited text no. 2
Luketich JD, Schauer PR, Christie NA, Weigel TL, Raja S, Fernando HC, et al. Minimally invasive esophagectomy. Ann Thorac Surg 2000;70:906-11.  Back to cited text no. 3
Palanivelu C, Prakash A, Senthilkumar R, Senthilnathan P, Parthasarathi R, Rajan PS, et al. Minimally invasive esophagectomy: Thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone position – Experience of 130 patients. J Am Coll Surg 2006;203:7-16.  Back to cited text no. 4
Rijnhart-De Jong HG, Draaisma WA, Smout AJ, Broeders IA, Gooszen HG. The Visick score: A good measure for the overall effect of antireflux surgery? Scand J Gastroenterol 2008;43:787-93.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04