# Ivor Lewis esophagectomy
Ivor Lewis esophagectomy is a two-field operation for esophageal cancer in which the esophagus is removed through the abdomen and the right chest, a tubularized gastric conduit is pulled into the chest, and the stomach is joined to the remaining esophagus inside the thorax. The McKeown three-stage operation, its alternative, places the anastomosis in the neck.[1](https://link.springer.com/content/pdf/10.1007/s00464-016-4938-2.pdf) Its main indications are tumors of the distal and middle esophagus and the esophagogastric junction (Siewert type I or II)[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC11475372/); for tumors above the carina (point where the windpipe splits into two bronchi) it is considered unfeasible because it might compromise resection margins.[3](https://jtd.amegroups.org/article/view/13601/11835)
| Key fact | Detail |
|---|---|
| Fields | Abdomen (laparotomy or laparoscopy) plus right chest (thoracotomy or thoracoscopy), with an intrathoracic anastomosis[1](https://link.springer.com/content/pdf/10.1007/s00464-016-4938-2.pdf) |
| Conduit | Tubularized stomach, with a standardized width of about 40 mm proposed to balance blood supply and emptying[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC11475372/) |
| Leak vs McKeown (minimally invasive) | 5.5% vs 14.7% across 23 cohort studies (OR 2.97 for McKeown)[4](https://tcr.amegroups.org/article/view/35992/html); in totally minimally invasive series the difference was not significant (4.7% vs 5.2%)[3](https://jtd.amegroups.org/article/view/13601/11835) |
| Recurrent laryngeal nerve injury | Lower with Ivor Lewis than McKeown (RR 0.14)[5](https://www.frontiersin.org/journals/surgery/articles/10.3389/fsurg.2022.950108/full); 1.7% vs 9.7% in one meta-analysis[4](https://tcr.amegroups.org/article/view/35992/html) |
| 30-day mortality | 2.2% (Ivor Lewis) vs 2.7% (McKeown), not significant[5](https://www.frontiersin.org/journals/surgery/articles/10.3389/fsurg.2022.950108/full) |
| Minimally invasive vs open | Pulmonary infection 9% vs 29% in the TIME trial[6](https://vats.amegroups.org/article/view/10635/html) |
## How it works
The operation replaces the esophagus with the stomach. Working through two fields allows lymphadenectomy at two stations: celiac and upper abdominal nodes during the abdominal phase, and peri-esophageal and subcarinal mediastinal nodes during the thoracic phase.[1](https://link.springer.com/content/pdf/10.1007/s00464-016-4938-2.pdf) The defining feature is the intrathoracic anastomosis. Compared with a cervical anastomosis, it is associated with lower leak rates, less stenosis, and fewer recurrent laryngeal nerve injuries; earlier series reported recurrent nerve lesions in 8% of patients with cervical anastomosis versus 1% with intrathoracic anastomosis.[1](https://link.springer.com/content/pdf/10.1007/s00464-016-4938-2.pdf) The counterweight is that an intrathoracic leak can produce empyema, and this risk motivated McKeown's three-stage approach with a cervical anastomosis.[1](https://link.springer.com/content/pdf/10.1007/s00464-016-4938-2.pdf)
## How it is done
The abdominal phase uses laparotomy or laparoscopy. The surgeon performs lymphadenectomy around the celiac trunk, mobilizes the stomach, and forms a gastric conduit, with a width of about 40 mm proposed as a standard.[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC11475372/)
The thoracic phase uses a right thoracotomy or thoracoscopy. In the prone thoracoscopic variant, double-lung ventilation is maintained with CO2 pneumothorax of 6–8 mmHg (maximum 8 mmHg), avoiding single-lung ventilation.[1](https://link.springer.com/content/pdf/10.1007/s00464-016-4938-2.pdf) The esophagus is mobilized, peri-esophageal and subcarinal lymphadenectomy is performed, and the conduit is brought up and joined to the esophagus within the chest.[1](https://link.springer.com/content/pdf/10.1007/s00464-016-4938-2.pdf) In Lewis's original description the two stages were separated by 1–2 weeks.
## Origin
In 1946, Ivor Lewis (1895–1982) introduced a standardized two-stage approach for carcinoma of the middle third of the esophagus: a laparotomy with celiac lymphadenectomy and gastric conduit formation, followed 1–2 weeks later by a right thoracotomy with esophageal resection, peri-esophageal and subcarinal lymphadenectomy, and intrathoracic anastomosis.[1](https://link.springer.com/content/pdf/10.1007/s00464-016-4938-2.pdf) The technique was first presented in his Hunterian Lecture at the [Royal College of Surgeons of England](https://www.edgepedia.org/royal-college-of-surgeons-of-england) on 10 January 1946 and published in the British Journal of Surgery that year.[7](https://doi.org/10.1002/bjs.18003413304) • [2](https://pmc.ncbi.nlm.nih.gov/articles/PMC11475372/) McKeown later developed the three-stage alternative with a cervical anastomosis in response to the risk of intrathoracic leak.[1](https://link.springer.com/content/pdf/10.1007/s00464-016-4938-2.pdf) A minimally invasive Ivor Lewis esophagectomy was reported by Bizekis and colleagues in 2006 in The Annals of Thoracic Surgery.[8](https://doi.org/10.1016/j.athoracsur.2006.02.052) Robotic versions followed: Kernstine and colleagues reported the first series of completely robotic esophagectomies with three-field lymphadenectomy in 2007 in Surgical Endoscopy[9](https://doi.org/10.1007/s00464-007-9405-7), and robot-assisted [thoracoscopic esophagectomy](https://www.edgepedia.org/thoracoscopic-esophagectomy) was described by Boone and colleagues in 2009 in the British Journal of Surgery[10](https://doi.org/10.1002/bjs.6647), by Kim and colleagues in the prone position in 2009 in the Journal of Thoracic and Cardiovascular Surgery[11](https://doi.org/10.1016/j.jtcvs.2009.05.030), and by Puntambekar and colleagues in 2011 in a series of 32 prone-position patients in the same journal.[12](https://doi.org/10.1016/j.jtcvs.2011.03.028)
## Variants
Three anastomotic techniques are used in minimally invasive Ivor Lewis esophagectomy: hand-sewn end-to-side, mechanical linear-stapled side-to-side, and mechanical circular-stapled end-to-side anastomoses.[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC11475372/) In a six-center European cohort of 282 minimally invasive Ivor Lewis procedures, linear and circular stapling gave leak rates of 13% versus 14.9% (\( p = 0.710 \)), and anastomotic technique did not predict leak.[1](https://link.springer.com/content/pdf/10.1007/s00464-016-4938-2.pdf) In robotic surgery no consensus exists on the optimal technique; hand-sewn and linear stapled methods allow a fully robotic anastomosis, while circular stapling requires undocking the robot but is considered the most reproducible for surgeons transitioning to robotics.[13](https://karger.com/dsu/article/42/4/204/928485/Robot-Assisted-Minimally-Invasive-Esophagectomy)
The TIME trial found pulmonary infection in 9% of minimally invasive patients versus 29% after open surgery, with no differences in R0 resections (complete tumor removal with cancer-free margins), lymph node yield, or 30-day mortality.[6](https://vats.amegroups.org/article/view/10635/html) The MIRO trial of hybrid Ivor Lewis esophagectomy found major complications in 36% versus 64% after open surgery, equal to 77% lower adjusted odds of major complications (aOR 0.23, 95% CI 0.12–0.44).[14](https://academic.oup.com/ejcts/article/59/6/1279/6100976) In the ROBOT trial, robotic surgery produced fewer pulmonary (32% vs 58%, \( p = 0.005 \)) and cardiac (22% vs 47%, \( p = 0.006 \)) complications than open surgery.[13](https://karger.com/dsu/article/42/4/204/928485/Robot-Assisted-Minimally-Invasive-Esophagectomy) The RAMIE trial, reported by Yang and colleagues in 2022[15](https://doi.org/10.1097/sla.0000000000005023), found superior mediastinal lymph node yield for robotic versus conventional minimally invasive surgery (15 vs 12, \( p = 0.033 \)).[13](https://karger.com/dsu/article/42/4/204/928485/Robot-Assisted-Minimally-Invasive-Esophagectomy) A 2025 meta-analysis of 16 studies (7,339 patients) found robotic Ivor Lewis esophagectomy had lower recurrent laryngeal nerve palsy (OR 0.13, 95% CI 0.06–0.31), anastomotic leak (OR 0.47, 95% CI 0.28–0.78), and respiratory complications (OR 0.53) than robotic McKeown.[16](https://link.springer.com/article/10.1007/s11701-025-02867-4)
## Applications
Published comparisons favor Ivor Lewis over McKeown on several short-term outcomes. A meta-analysis of 8 studies with 3,291 patients (1,857 Ivor Lewis, 1,434 McKeown) found a lower all-grade anastomotic leak rate (RR 0.67, 95% CI 0.55–0.82) and lower recurrent laryngeal nerve injury (RR 0.14, 95% CI 0.08–0.25) for Ivor Lewis, with 30-day mortality of 2.2% versus 2.7% (not significant).[5](https://www.frontiersin.org/journals/surgery/articles/10.3389/fsurg.2022.950108/full) A meta-analysis of 23 cohort studies with 4,933 patients found leakage in 5.5% after minimally invasive Ivor Lewis versus 14.7% after minimally invasive McKeown, with lower 90-day mortality (3.2% vs 8.9%), less stricture (4.1% vs 10.0%), and similar R0 rates (96.8% vs 97.2%).[4](https://tcr.amegroups.org/article/view/35992/html) In totally minimally invasive esophagectomy specifically, however, a meta-analysis of five studies with 1,681 patients found no significant leak difference (4.7% Ivor Lewis vs 5.2% McKeown, RR 1.39, \( p = 0.14 \)).[3](https://jtd.amegroups.org/article/view/13601/11835) In the six-center European minimally invasive cohort (282 patients, 90.2% receiving neoadjuvant therapy), leakage was 15.2%, pulmonary complications 13.3%, [R0 resection](https://www.edgepedia.org/r0-resection) 92.5%, and 30-day/in-hospital mortality 2.1%.[1](https://link.springer.com/content/pdf/10.1007/s00464-016-4938-2.pdf)
## Limitations and alternatives
Ivor Lewis esophagectomy suits tumors of the distal esophagus (middle or lower third) through the esophagogastric junction (Siewert type I or II); cervical, proximal thoracic, and Siewert type III locations are limitations, and tumors above the carina make the approach unfeasible because resection margins may be compromised.[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC11475372/) • [3](https://jtd.amegroups.org/article/view/13601/11835) Compared with transhiatal esophagectomy, transthoracic approaches yield more lymph nodes (mean difference 8.3 nodes, \( p < 0.001 \)) but more pulmonary complications, with comparable R0 rates and 5-year overall survival.[16](https://link.springer.com/article/10.1007/s11701-025-02867-4) Main failure modes include anastomotic leak, which in the European cohort produced empyema requiring thoracotomy and decortication in 4.6% of all patients[1](https://link.springer.com/content/pdf/10.1007/s00464-016-4938-2.pdf), chylothorax, recurrent laryngeal nerve injury, and anastomotic stricture.[4](https://tcr.amegroups.org/article/view/35992/html) Preoperative radiation dose to the gastric fundus, where conduit perfusion is most vulnerable, was associated with anastomotic complications.[1](https://link.springer.com/content/pdf/10.1007/s00464-016-4938-2.pdf) The McKeown three-stage operation with a cervical anastomosis remains the main alternative when the intrathoracic leak risk is to be avoided.[1](https://link.springer.com/content/pdf/10.1007/s00464-016-4938-2.pdf)
## References
1. [Techniques and short-term outcomes for total minimally invasive Ivor Lewis esophageal resection in distal esophageal and gastroesophageal junction cancers: pooled data from six European centers (Surg Endosc)](https://link.springer.com/content/pdf/10.1007/s00464-016-4938-2.pdf)
2. [Surgical Technique and Implementation of Total Minimally Invasive (Laparo-Thoracoscopic) Ivor Lewis Esophagectomy for Cancer](https://pmc.ncbi.nlm.nih.gov/articles/PMC11475372/)
3. [McKeown or Ivor Lewis totally minimally invasive esophagectomy: systematic review and meta-analysis (van Workum et al., Journal of Thoracic Disease 2017)](https://jtd.amegroups.org/article/view/13601/11835)
4. [McKeown or Ivor Lewis minimally invasive esophagectomy: a systematic review and meta-analysis (Wang et al., Translational Cancer Research)](https://tcr.amegroups.org/article/view/35992/html)
5. [Short-term outcomes of Ivor Lewis vs. McKeown esophagectomy: A meta-analysis (Xing et al., Frontiers in Surgery 2022)](https://www.frontiersin.org/journals/surgery/articles/10.3389/fsurg.2022.950108/full)
6. [Conventional and robot-assisted minimally invasive esophagectomy: literature review of the current state and future directions (Video-Assisted Thoracic Surgery)](https://vats.amegroups.org/article/view/10635/html)
7. [Ivor Lewis (1946). The surgical treatment of carcinoma of the oesophagus with special reference to a new operation for growths of the middle third. British journal of surgery.](https://doi.org/10.1002/bjs.18003413304)
8. [Costas Bizekis and colleagues (2006). Initial Experience With Minimally Invasive Ivor Lewis Esophagectomy. The Annals of Thoracic Surgery.](https://doi.org/10.1016/j.athoracsur.2006.02.052)
9. [K. H. Kernstine and colleagues (2007). The first series of completely robotic esophagectomies with three-field lymphadenectomy: initial experience. Surgical Endoscopy.](https://doi.org/10.1007/s00464-007-9405-7)
10. [J Boone and colleagues (2009). Robot-assisted thoracoscopic oesophagectomy for cancer. British journal of surgery.](https://doi.org/10.1002/bjs.6647)
11. [Dae Joon Kim and colleagues (2009). Thoracoscopic esophagectomy for esophageal cancer: Feasibility and safety of robotic assistance in the prone position. Journal of Thoracic and Cardiovascular Surgery.](https://doi.org/10.1016/j.jtcvs.2009.05.030)
12. [Shailesh Padmakar Puntambekar and colleagues (2011). Robotic transthoracic esophagectomy in the prone position: Experience with 32 patients with esophageal cancer. Journal of Thoracic and Cardiovascular Surgery.](https://doi.org/10.1016/j.jtcvs.2011.03.028)
13. [Robot-Assisted Minimally Invasive Esophagectomy: Current Best Practice (Digestive Surgery, Karger)](https://karger.com/dsu/article/42/4/204/928485/Robot-Assisted-Minimally-Invasive-Esophagectomy)
14. [Hybrid robotic versus hybrid laparoscopic Ivor Lewis oesophagectomy: a case-matched analysis (EJCTS)](https://academic.oup.com/ejcts/article/59/6/1279/6100976)
15. [Yang Yang and colleagues (2022). Robot-assisted Versus Conventional Minimally Invasive Esophagectomy for Resectable Esophageal Squamous Cell Carcinoma: Early Results of a Multicenter Randomized Controlled Trial: the RAMIE Trial.. PubMed.](https://doi.org/10.1097/sla.0000000000005023)
16. [Comparative analysis of robotic Ivor Lewis, McKeown, and transhiatal esophagectomy: a comprehensive systematic review and meta-analysis (J Robotic Surgery 2025)](https://link.springer.com/article/10.1007/s11701-025-02867-4)
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*Topic: Encyclopedia › Life and health › Human health and medicine › Clinical assessment and procedures › Surgery and surgical specialties › Gastrointestinal and abdominal wall surgery procedures › Esophageal surgery procedures*
*Initially written Sep 29, 2026 · Edited: Oct 15, 2026*
*Copyright 2026 EdgeChat AI, a subsidiary of Biostate AI.*
License: Edgepedia Community License 1.0, https://www.edgepedia.org/edgepedia/license