Mediastinoscopic esophagectomy with lymph node dissection using a bilateral transcervical and transhiatal pneumomediastinal approach

Abstract

We developed a method for mediastinoscopic esophagectomy via a bilateral transcervical and transhiatal approach under pneumomediastinum as a less-invasive radical operation. The right recurrent nerve is first identified using an open approach, and the right cervical paraesophageal lymph nodes and part of the right recurrent nerve lymph nodes are dissected, after which pneumomediastinum is initiated. The upper thoracic paraesophageal lymph nodes and right recurrent nerve lymph nodes are dissected along the right vagus nerve. The dorsal side of the esophagus is dissected along the visceral sheath taking care to avoid thoracic duct injury and is then dissected along the vascular sheath in front of the descending aorta. The esophagus is dissected from the trachea at the caudal side of the aortic arch, and then dissected along the ventral side of the left main bronchus, reaching the pulmonary artery. Finally, the right recurrent nerve lymph nodes around the right subclavian artery are completely retrieved. The left cervical approach is almost the same as that via the right side. The dorsal side of the esophagus is almost dissected along the visceral sheath with a right transcervical approach. The subaortic arch to the left tracheobronchial lymph nodes are dissected using the crossover technique. These lymph nodes are easily dissected by cutting the left and ventral side of the lymph nodes because the caudal side is already dissected in the right transcervical approach. A bilateral (especially right trans-cervico-pneumomediastinal) approach is useful for bilateral upper mediastinal lymph node dissection and esophagectomy.

Keywords

Minimally invasive esophagectomy / cervical approach / esophageal cancer / mediastinoscopic esophagectomy / pneumomediastinum / mediastinoscopic esophagectomy with lymph node dissection

References

[1] Brierley JD,Wittekind C. TNM classification of malignant tumours. 8th ed. UK: John Wiley & Sons, Ltd; 2017. Available from: http://mom.gov.az/resources/content_files/ebook/TNM-Classification-of-Malignant-Tumours-8th-edition.pdf. [Last accessed on 15 May 2020]

[2] Tachimori Y,Numasaki H,Matsubara H.Comprehensive registry of esophageal cancer in Japan, 2012..Esophagus2019;16:221-45 PMCID:PMC6592979

[3] Lewis I.The surgical treatment of carcinoma of the oesophagus; with special reference to a new operation for growths of the middle third..Br J Surg1946;34:18-31

[4] McKeown KC.Trends in oesophageal resection for carcinoma with special reference to total oesophagectomy..Ann R Coll Surg Engl1972;51:213-39 PMCID:PMC2388099

[5] Biere SS,Maas KW,Rosman C.Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial..Lancet2012;379:1887-92

[6] Akaishi T,Higuchi N,Kuramoto J.Thoracoscopic en bloc total esophagectomy with radical mediastinal lymphadenectomy..J Thorac Cardiovasc Surg1996;112:1533-40

[7] Nguyen NT,Lemoine PH,Goodnight JE Jr.Minimally invasive Ivor Lewis esophagectomy..Ann Thorac Surg2001;72:593-6

[8] Luketich JD,Christie NA,Raja S.Minimally invasive esophagectomy..Ann Thorac Surg2000;70:906-11

[9] Kawahara K,Okabayashi K,Shiraishi T.Video-assisted thoracoscopic esophagectomy for esophageal cancer..Surg Endosc1999;13:218-23

[10] Takeuchi H,Ozawa S,Osugi H.Comparison of short-term outcomes between open and minimally invasive esophagectomy for esophageal cancer using a nationwide database in Japan..Ann Surg Oncol2017;24:1821-7

[11] Cuschieri A,Banting S.Endoscopic oesophagectomy through a right thoracoscopic approach..J R Coll Surg Edinb1992;37:7-11

[12] Akiyama H.Esophagectomy without thoracotomy..Surg Annu1981;13:109-21

[13] Orringer MB.Esophagectomy without thoracotomy..J Thorac Cardiovasc Surg1978;76:643-54

[14] Tangoku A,Abe T,Satou T.Mediastinoscope-assisted transhiatal esophagectomy for esophageal cancer..Surg Endosc2004;18:383-9

[15] Tokairin Y,Fujiwara H,Okuda M.Mediastinoscopic subaortic and tracheobronchial lymph node dissection with a new cervico-hiatal crossover approach in thiel-embalmed cadavers..Int Surg2015;100:580-8 PMCID:PMC4400922

[16] Tokairin Y,Kawada K,Okada T.A mediastinoscopic approach with bilateral cervicopneumomediastinum in radical thoracic esophagectomy..Int Surg2017;102:278-83

[17] Tokairin Y,Kawada K,Okada T.The usefulness of a bilateral transcervical pneumomediastinal approach for mediastinoscopic radical esophagectomy: a right transcervical approach is an available option..Gen Thorac Cardiovasc Surg2019;67:884-90

[18] Tokairin Y,Kawada K,Okada T.A feasibility study of mediastinoscopic radical esophagectomy for thoracic esophageal cancer from the viewpoint of the dissected mediastinal lymph nodes validated with thoracoscopic procedure: a prospective clinical trial..Esophagus2019;16:214-9

[19] Fujiwara H,Konishi H,Komatsu S.Single-Port Mediastinoscopic Lymphadenectomy Along the Left Recurrent Laryngeal Nerve..Ann Thorac Surg2015;100:1115-7

[20] Mori K,Yagi K,Mitsui T.Technical details of video-assisted transcervical mediastinal dissection for esophageal cancer and its perioperative outcome..Ann Gastroenterol Surg2017;1:232-7 PMCID:PMC5881365

[21] Nakajima Y,Nakajima Y,Nagai K.Anatomical study of the left superior mediastinal lymphatics for tracheal branches of left recurrent laryngeal nerve-preserving mediastinoscope-assisted surgery in esophageal cancer..Surg Today2018;48:333-7

[22] Murakami M,Goto S,Yamashita T.Thoracoscopic and hand assisted laparoscopic esophagectomy with radical lymph node dissection for esophageal squamous cell carcinoma in the left lateral decubitus position: a single center retrospective analysis of 654 patients..BMC Cancer2017;17:748 PMCID:PMC5681806

[23] Randolph GW,Wilkins J.Recurrent laryngeal nerve identification and assessment during thyroid surgery: laryngeal palpation..World J Surg2004;28:755-60