<s>[INST] context: In transhiatal esophagectomy (THE) the thorax doesn’t need to be opened. Esophagus is removed through the diaphragmatic hiatus by making incisions in the abdomen and the neck.
In this operation, first, an upper abdominal incision is made. The surgeon mobilizes the esophagus by working upward through the diaphragmatic hiatus.
With the addition of an incision on the left side of the neck, the surgeon completes the mobilization of the esophagus, removes it, and moves the stomach upward through the hiatus and into the chest until its upper end appears in the neck wound. The remaining esophagus is connected to the stomach in the neck (cervical esophagogastric anastomosis).


Advantages of Transhiatal esophagectomy over transthoracic esophagectomy:
The two leading causes of morbidity and mortality in the first few days after a transthoracic esophagectomy are

Lung complications (especially pneumonia) associated with a large operation that requires opening both the chest and the abdomen. The pain of these combined incisions may make it difficult for the patient to take a deep breath early after the operation, and this allows pneumonia to set in; and
Severe infection in the chest (mediastinitis) resulting due to a "leak" from the intrathoracic esophagogastric anastomosis.

After a THE, because the patient has not had the chest opened, there is less pain early after surgery, the patient can move about better as a result, and lung complications are less.
Furthermore, if an anastomotic leak occurs, it can be easily managed by a simple cervical drainage as the anastomosis here is placed in the neck. [/INST] question: Transhiatal esophagectomy was planned for adenocarcinoma of the lower end of esophagus. The approach would be in the following order: | options: A: Abdomen-Neck B: Abdomen-Thorax-Neck C: Neck-Thorax-Abdomen D: Abdomen-Thorax | answer: A </s>