Indications and patient preparation
Opening of the cervical esophagus is performed under a number of strict surgical indications. These include foreign bodies that cannot be removed endoscopically (during esophagoscopy), traumatic injuries to the organ wall, presence of diverticula, tumor lesions, and persistent cicatricial strictures of the lumen.
For a successful intervention, the patient is placed in the supine position with a mandatory roll placed under the shoulder blades. The head must be extended and turned to the right, as the operating surgeon traditionally stands on the left side of the operating table. Anesthesia is performed using general anesthesia or local anesthesia. The latter option is often preferred because it allows the surgeon to communicate with the patient and monitor the preservation of the recurrent laryngeal nerve function through their voice.
Layer-by-layer topographic approach
The incision is made on the left side of the neck, guided by the anterior border of the sternocleidomastoid muscle. The line of incision runs from the jugular notch of the sternum to the level of the upper edge of the thyroid cartilage.
The surgeon sequentially dissects the tissues:
- Skin and subcutaneous adipose tissue.
- Platysma (platysma) along with the superficial fascia (encountered veins are ligated and divided strictly between applied clamps).
- Opens the anterior leaf of the sheath of the sternocleidomastoid muscle, after which the muscle itself is bluntly retracted laterally.
Next comes the deep stage. The posterior leaf of the muscular sheath, the third fascia of the neck, and the common fascial sheath of the neurovascular bundle are carefully dissected. This bundle (including the internal jugular vein and vagus nerve) along with the sternocleidomastoid muscle is retracted laterally. At the upper boundary of the wound, between two ligatures, the omohyoid muscle is divided. The remaining medial structures — the sternohyoid and sternothyroid muscles, the lateral lobe of the thyroid gland, and the trachea — are gently retracted medially.
Exposure and opening of the lumen
The esophagus lies deep between the trachea and the vertebral column. Visually, it is easily recognized by its pinkish-gray color and pronounced longitudinally directed muscle bundles. In the loose connective tissue on the anterior wall of the organ, the left recurrent laryngeal nerve must be identified and carefully retracted with a blunt hook. The left inferior thyroid artery (a. thyroidea inferior), passing through this zone, is ligated if necessary.
To open the organ, two stay sutures are placed on its wall, by which the tissue is lifted into a fold, while the surrounding space is thoroughly isolated with gauze sponges. First, the muscular layer is dissected with a scalpel down to the mucous membrane. Then the mucosa is grasped with anatomical forceps and opened with scissors.
If the surgery is performed for a foreign body, the tactics depend on the condition of the tissues: if the wall is severely altered, a healthy area above it is incised, and in the absence of pathological changes, the incision is made directly over the trapped object.
Wound closure and management of complications
Closure of a clean esophageal wound is performed in two stages:
- First row: deep interrupted catgut sutures through all layers of the wound edges. Placement begins from the angles of the incision, applying slight traction on the stay sutures.
- Changing of drapes: the surgical team must change their gloves and isolation drapes.
- Second row: outer interrupted silk sutures capturing only the adventitia and part of the muscle layer.
The suture line is reliably covered by restoring the previously divided omohyoid muscle. The operation is completed by placing interrupted catgut sutures on the fascial sheaths of the muscles and silk sutures on the skin.
In case of purulent inflammation of the paraesophageal tissue, the tactics change cardinally. The skin wound is closed only at the angles. A temporary esophagostomy is formed in the center by suturing the edges of the esophageal incision to the skin. Drainage must be left in the affected tissue. Patient nutrition during this period is organized via a feeding tube or, in severe cases, via a gastrostomy.
Briefly: answers to topical questions
Which elements make up the main neurovascular bundle of the neck, which is retracted laterally during an esophagotomy?
The main (medial) neurovascular bundle of the neck, which is retracted laterally during the approach to the esophagus, includes the following elements:
- Common carotid artery (a. carotis communis) — located medially.
- Internal jugular vein (v. jugularis interna) — located laterally.
- Vagus nerve (n. vagus) — lies between the artery and the vein, posterior to them.
- Deep cervical lymph nodes — located along the bundle.
The entire neurovascular bundle is enclosed in a common fascial sheath.
Which cervical fasciae according to Shevkunenko's classification are sequentially dissected during the approach to the cervical esophagus?
During the surgical approach to the cervical esophagus, the following cervical fasciae are sequentially dissected:
- Superficial fascia of the neck (1st fascia) — dissected together with the platysma (platysma).
- Deep fascia of the neck (2nd fascia) — the anterior and then the posterior leaf of the fascial sheath of the sternocleidomastoid muscle are opened.
- Omoclavicular fascia (3rd fascia) — dissected after retracting the muscle laterally.
- Endocervical fascia (4th fascia) — its parietal layer, which forms the common fascial sheath of the neurovascular bundle, is dissected.
At the level of which vertebrae is the cervical esophagus located (skeletotopy)?
The cervical esophagus extends from the sixth cervical to the third thoracic vertebra.
- Upper border — corresponds to the lower edge of the sixth cervical vertebra (C6), where the pharynx transitions into the esophagus (at the level of the lower edge of the cricoid cartilage).
- Lower border — is located at the level of the third thoracic vertebra (Th3).
What histological layers make up the wall of the cervical esophagus?
The wall of the cervical esophagus consists of five histological layers:
- mucous membrane (mucosa), lined with non-keratinizing stratified squamous epithelium;
- muscularis mucosae (muscularis mucosa);
- submucosa (submucosa);
- muscular layer (muscularis propria);
- adventitia (adventitia).
In surgical practice, the wall is considered as two sheaths: the inner one — mucosa and submucosa; the outer one — muscular layer and adventitia.
Which arteries supply blood to the cervical esophagus?
Blood supply to the cervical esophagus is provided by esophageal branches of the inferior thyroid arteries.
- Inferior thyroid artery (a. thyroidea inferior) — is a branch of the thyrocervical trunk of the subclavian artery.
In the neck, the left inferior thyroid artery runs transversely 1–2 cm below the beginning of the esophagus. When performing an esophagotomy, this artery is identified in the loose connective tissue on the anterior wall of the esophagus and ligated if necessary.
To avoid confusion during the approach, remember the rule of tissue retraction: "Outside — the bundle, inside — the gland and trachea." The neurovascular bundle and sternocleidomastoid muscle are always pulled laterally, while the thyroid gland and airway are pulled medially.
Class and exam questions
Why is surgery sometimes preferentially performed under local anesthesia?
Local anesthesia leaves the patient conscious, giving the surgeon the opportunity to constantly monitor the patient's voice and thereby verify the integrity of the recurrent laryngeal nerve.
How to visually distinguish the esophageal wall from other neck structures?
The wall of the cervical esophagus has a characteristic pinkish-gray hue, and longitudinally directed muscle bundles are clearly visible on its surface.
How to properly open the esophagus over a foreign body if the wall is inflamed?
If the wall over a foreign body is severely altered or necrotic, the lumen must not be opened directly over the object. The incision is made within a healthy area of the wall above it.
What else to study on this topic
- Topographic anatomy and cervical fascia according to Shevkunenko are within reach.
- Features of the course and branching of the left recurrent laryngeal nerve.
- Technique of intestinal suturing (Albert's two-row suture).
- Principles of gastrostomy formation for nutritional support in severe patients.
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