Advances and understanding pitfalls of laparoscopic transhiatal esophagectomy with en bloc mediastinal lymph node dissection

Abstract

We began performing mediastinal lymph node dissection using the laparoscopic transhiatal approach in 2009. Following the initiation of the single-port mediastinoscopic cervical approach in 2014, we developed a technique for transmediastinal radical esophagectomy without a thoracic approach. We herein describe our surgical procedures for en bloc mediastinal lymph node dissection by the laparoscopic transhiatal approach with a focus on pitfalls. We opened the esophageal hiatus and the working space was secured using long retractors. During division of the right crus of the diaphragm, we made efforts to avoid damaging the left hepatic vein and inferior vena cava. Dissection of the posterior plane of the pericardium was extended to the cranial side, and the bilateral inferior pulmonary veins were identified. To avoid misorientation, the posterior plane was initially extended along the long axis of the esophagus. The anterior and posterior sides of the posterior mediastinal lymph nodes were then both dissected. These lymph nodes were lifted in a sheet-like form and then cut along the borderline of the left mediastinal pleura. The right side of the mediastinal lymph nodes was then dissected. To avoid damaging the arch of the azygos vein, it was identified at the dorsal side of the right main bronchus prior to lymph node dissection. This procedure decreased the total operative time, total operative bleeding, and postoperative respiratory complications without reducing the quality of lymphadenectomy. In conclusion, the procedure described herein resulted in a good surgical view and safe en bloc mediastinal lymph node dissection. A detailed understanding of mediastinal 3D anatomy and specific pitfalls is crucial for the successful use of this approach.

Keywords

Transmediastinal radical esophagectomy / laparoscopic transhiatal approach / pitfall

References

[1] Tachimori Y,Numasaki H,Shinoda M.Efficacy of lymph node dissection by node zones according to tumor location for esophageal squamous cell carcinoma..Esophagus2016;13:1-7 PMCID:PMC4698372

[2] Udagawa H,Shinohara H,Kaida S.The importance of grouping of lymph node stations and rationale of three-field lymphoadenectomy for thoracic esophageal cancer..J Surg Oncol2012;106:742-7

[3] Tachimori Y,Numasaki H,Matsubara H.Comprehensive registry of esophageal cancer in Japan, 2012..Esophagus2019;16:221-245 PMCID:PMC6592979

[4] Orringer MB.Esophagectomy without thoracotomy..J Thorac Cardiovasc Surg1978;76:643-53

[5] DePaula AL,Ferreira EA,Grecco E.Laparoscopic transhiatal esophagectomy with esophagogastroplasty..Surg Laparosc Endosc1995;5:1-5

[6] Bonavina L,Binyom PR.A laparoscopy-assisted surgical approach to esophageal carcinoma..J Surg Res2004;117:52-7

[7] Montenovo MI,Pellegrini CA.Outcomes of laparoscopic-assisted transhiatal esophagectomy for adenocarcinoma of the esophagus and esophago-gastric junction..Dis Esophagus2011;24:430-6

[8] Shiozaki A,Murayama Y,Kuriu Y.Posterior mediastinal lymph node dissection using the pneumomediastinum method for esophageal cancer..Esophagus2012;9:58-64

[9] Shiozaki A,Murayama Y,Kuriu Y.Hand-assisted laparoscopic transhiatal approach for mediastinal esophageal duplication cyst resection..Esophagus2012;9:247-51

[10] Shiozaki A,Murayama Y,Kuriu Y.Perioperative outcomes of esophagectomy preceded by the laparoscopic transhiatal approach for esophageal cancer..Dis Esophagus2014;27:470-8

[11] Shiozaki A,Konishi H,Kosuga T.Hand-assisted technique beneficial for laparoscopic transhiatal esophagectomy with en-bloc dissection of middle and lower mediastinal lymph nodes: roles of the operator’s left hand..Esophagus2017;14:138-45

[12] Shiozaki A,Konishi H,Murayama Y.Novel technique for dissection of subcarinal and main bronchial lymph nodes using a laparoscopic transhiatal approach for esophageal cancer..Anticancer Res2013;33:2577-85

[13] Fujiwara H,Konishi H,Kubota T.Hand-assisted laparoscopic transhiatal esophagectomy with a systematic procedure for en bloc infracarinal lymph node dissection..Dis Esophagus2016;29:131-8

[14] Fujiwara H,Konishi H,Komatsu S.Single-Port mediastinoscopic lymphadenectomy along the left recurrent laryngeal nerve..Ann Thorac Surg2015;100:1115-7

[15] Fujiwara H,Konishi H.Mediastinoscope and laparoscope-assisted esophagectomy..J Vis Surg2016;2:125 PMCID:PMC5638202

[16] Fujiwara H,Konishi H,Komatsu S.Perioperative outcomes of single-port mediastinoscope-assisted transhiatal esophagectomy for thoracic esophageal cancer..Dis Esophagus2017;30:1-8

[17] Fujiwara H,Konishi H.Transmediastinal approach for esophageal cancer: A new trend toward radical surgery..Asian J Endosc Sur2019;12:30-6

[18] Shiozaki A,Konishi H,Komatsu S.Successful subcarinal dissection using a laparoscopic transhiatal approach for esophageal cancer with an anomalous pulmonary vein..Gen Thorac Cardiovasc Surg2016;64:239-42

[19] Yoshimura S,Yamagata Y,Yagi K.Quality of life after robot-assisted transmediastinal radical surgery for esophageal cancer..Surg Endosc2018;32:2249-54 PMCID:PMC5897479

[20] Sugawara K,Yagi K,Aikou S.Long-term health-related quality of life following robot-assisted radical transmediastinal esophagectomy..Surg Endosc2020;34:1602-11

[21] Seto Y.Essential Updates 2018/2019: Essential Updates for esophageal cancer surgery..Ann Gastroenterol Surg2020;4:190-4 PMCID:PMC7240138

[22] Seto Y,Aikou S.Robotic surgery for esophageal cancer: merits and demerits..Ann Gastroenterol Surg2017;1:193-8 PMCID:PMC5881348