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The short-term advantages of minimally invasive esophagectomy (MIE) in terms of less morbidity and better Quality of Life (QoL) in comparison with open esophagectomy (OE) became visible in the last few years. There are two main MIE approaches: a transthoracic resection (TTE; either accompanied by an intrathoracic or cervical anastomosis) or a transhiatal resection (THE; accompanied by a cervical anastomosis). However, controversy about what approach is best for gastro-esophageal junction tumors (GEJ) still exists and the choice of the approach is currently based on the surgeons’ discretion. In this chapter, we describe the indications for each minimally invasive approach for GEJ tumors, the surgical technique, the most common complications and their treatment, our own experiences, patient-survival rates, current developments and problems regarding surgical treatment for patients with cancer of the GEJ.

A transthoracic approach (Ivor Lewis and McKeown) allows dissection of the difficult esophagus under direct vision and may improve extent of lymphadenectomy and radial margin for midesophageal tumors. Cervical anastomosis in the McKeown esophagectomy allows for a greater length of the proximal esophagus to be resected. Thus many surgeons prefer this approach for middle and upper esophageal tumors. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

In this chapter, we will outline our technique for laparoscopic and thoracoscopic transhiatal esophagectomy with cervical anastomosis. We utilize this technique routinely in patients with esophageal and Siewert’s types 1 and 2 gastroesophageal junction cancer. This technique has been shown to be safe in the setting of neoadjuvant chemoradiation since most patients in the western world present with locally advanced carcinoma and receive multimodality treatment. This technique is best reserved for those patients who have no history of previous gastric surgery such as a Nissen fundoplication. In such patients, the amount of gastric conduit available to reach the neck may be limited and an intrathoracic esophagogastric anastomosis may be preferable as described in other portions of this book.