Ann Thorac Surg 2002;73:1329-1331
© 2002 The Society of Thoracic Surgeons
How to do it
Thoracoscopic esophagectomy combined with mediastinoscopy via the neck
Yoshifumi Ikeda, MD*a,
Masanori Niimi, MD, PhDa,
Shigenao Kan, MDa,
Hiroshi Takami, MDa,
Susumu Kodaira, MDa
a Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
Accepted for publication November 28, 2001.
* Address reprint requests to Dr Ikeda, Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan
e-mail: yikeda{at}med.teikyo-u.ac.jp
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Abstract
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Although thoracoscopic techniques have been introduced to esophageal surgery, the identification of the left recurrent laryngeal nerve and lymph node dissection along the nerve remain quite difficult. A mediastinoscopic technique via the neck enables an excellent visual field to be created in the upper mediastinum, especially near the left recurrent laryngeal nerve. Therefore, a thoracoscopic esophagectomy combined with this technique allows mediastinal lymph nodes along the left recurrent laryngeal nerve to be easily and safely dissected.
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Introduction
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An esophagectomy is the procedure of choice for the treatment of localized esophageal carcinoma. Despite recent improvements in perioperative morbidity and mortality, en bloc esophagectomy using a conventional thoracotomy is still considered to be an invasive procedure. Thoracoscopic techniques have been introduced to the field of esophageal surgery to avoid the need for conventional thoracotomies [1, 2]. Many patients with thoracic esophageal carcinoma experience lymph node recurrences in the upper mediastinum, especially along the left recurrent laryngeal nerve [3]. Lymph nodes along the left recurrent laryngeal nerve are difficult to dissect using thoracoscopic procedures, because the nerve often cannot be visualized [2]. Thus, the risk of paralysis is high. In this article, we report a combination of mediastinoscopic and thoracoscopic procedures that allows lymph nodes along the left recurrent laryngeal nerve to be safely and easily dissected.
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Technique
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The patient is placed in a supine position with the neck slightly extended while under general anesthesia. A 10-cm left cervical collar incision is made. The left recurrent laryngeal nerve in the cervix is exposed, and the cervical esophagus is dissected circumferentially using the conventional procedure. Two 5-mm trocars for endoscopic instruments are placed in position, one at the suprasternal notch and one lateral to the incision. A cervical incision is closed with interrupted sutures to prevent gas leakage, and an additional 5-mm trocar is inserted through the center of this incision (Fig 1A).
Carbon dioxide is then insufflated up to a pressure of 4 mm Hg, and a 30°, 5-mm endoscope is inserted through the central 5-mm trocar. The left recurrent laryngeal nerve is separated from the lymph nodes and surrounding tissues until the aortic arch and the left vagus nerve have been identified (Fig 2A).
The upper mediastinal esophagus is cut using a 60-mm linear stapler (Auto Suture; United States Surgical Corp, Norwalk, CT) at the neck. Next, a 7-cm incision is made in the upper medial abdomen, and three 10-mm trocars are inserted (Fig 1A). Combined with a hand-assisted technique, the gastrocolic omentum, short gastric vessels, and phrenoesophageal ligament are divided along the greater curvature with a Harmonic Scalpel (Johnson-Johnson Medical, Cincinnati, OH) and endoscopic scissors, and the right gastroepiploic vascular arcade is preserved to maintain a blood supply to the gastric tube. The left gastric artery and vein are divided with clips, and the abdominal esophagus is finally dissected. Then, the stomach is pulled out of the 7-cm wound and a narrow gastric tube fashioned along the greater curvature is created using a 60-mm linear stapler. The gastric tube is then pulled through the cervical incision under the sternum. The anastomosis between the cervical esophagus and the gastric tube was performed using a circular stapling device (Auto Suture) in an end-to-side fashion. The patient is then intubated using a double-lumen tube for single lung ventilation and positioned in the left lateral decubitus position. Four 10-mm ports are placed for the thoracoscopic surgery (Fig 1B). The mediastinal pleura overlying the esophagus is divided, and the entire thoracic esophagus is exposed. The azygos vein is divided using the endoscopic vascular stapler (Auto Suture). Circumferential mobilization of the esophagus, with all of the surrounding lymph nodes, subcarinal nodes, periesophageal tissue and fat, and the mediastinal pleura is performed from the diaphragmatic reflection to the thoracic inlet. After identifying the right recurrent laryngeal nerve, lymph nodes from the upper esophagus and the nerve area are gently dissected. The left recurrent laryngeal nerve can be easily identified, and lymphadenectomy along the nerve can be safely performed, because the nerve has already been separated from the surrounding lymph nodes, tissue, and fat during the mediastinoscopic procedure via the neck (Fig 2B). The specimen is placed in a plastic bag (Auto Suture) and removed through the incision of the camera port. We have used this procedure in 5 patients with thoracic esophageal squamous cell carcinoma which invaded into muscularis propria by preoperative diagnosis. Three patients had tumors in the upper thoracic portion and 2 in the middle thoracic portion. Based on the T stage and the clinical stage from the TNM Classification of the Oesophagus [4] after resection, one patient had T1 and 4 had T2, and 2 had stage IIA and 3 had stage IIB. Oncologic curative resections were performed in all patients. They were able to walk within 24 hours after the operation and were discharged 2 weeks after the surgery without any complications.
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Fig 1. The schema of surgical incisions and location of the ports for mediastinoscopic and laparoscopic hand-assisted procedure in a supine position (A), and thoracoscopic procedure in the left lateral decubitus position (B).
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Fig 2. The left recurrent laryngeal nerve and mediastinal lymph nodes are clearly identified through the mediastinoscope looking from the neck down into the upper mediastinum (A). The lymph nodes surrounding the left recurrent laryngeal nerve can be easily dissected by the thoracoscopic procedure (B).
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Comment
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Thoracoscopic esophagectomy bears the risk of damage to the left recurrent laryngeal nerve when lymph node sampling or complete dissection around the nerve is performed because the nerve frequently cannot be visualized during the procedure [2]. We have found that endoscopic techniques using carbon dioxide insufflation enable an excellent visual field to be created in the upper mediastinum, especially near the left recurrent laryngeal nerve [5, 6]. Therefore, we attempted to use this technique prior to performing thoracoscopic esophagectomies in patients with lymph node metastases around the left recurrent laryngeal nerve. This procedure enabled the mediastinal lymph nodes along the left recurrent laryngeal nerve to be easily dissected during the thoracoscopic procedure in all 5 of our patients, and no complications including nerve paralysis occurred. Although radiation therapy after an esophagectomy may be sufficient treatment in cases with lymph node metastases around the left recurrent laryngeal nerve, surgical dissection using our technique is a useful choice. Since complete resection with free surgical margin is difficult to perform in T3 or T4 cases by thoracoscopic procedure, our procedure is indicated in T1 or T2 cases with upper mediastinal lymph node metastases.
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References
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Law S., Fok M., Chu K.M., Wong J. Thoracoscopic esophagectomy for esophageal cancer. Surgery 1997;122:8-14.[Medline]
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Luketich J.D., Schauer P.R., Christie N.A., et al. Minimally invasive esophagectomy. Ann Thorac Surg 2000;70:906-912.[Abstract/Free Full Text]
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Ando N., Ozawa S., Kitagawa Y., Shinozawa Y., Kitajima M. Improvement in the results of surgical treatment of advanced squamous esophageal carcinoma during 15 consecutive years. Ann Surg 2000;232:225-232.[Medline]
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Hermanek P., Sobin L.H., International Union Against Cancer (UICC). TNM classification of malignant tumors, 4th ed. Berlin: Springer, 1992.
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Ikeda Y., Takami H., Sasaki Y., Kan S., Niimi M. Endoscopic neck surgery by the axillary approach. J Am Coll Surg 2000;191:336-340.[Medline]
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Ikeda Y., Niimi M., Sasaki Y., et al. Mediastinoscopic esophagectomy using carbon dioxide insufflation via the neck approach. Surgery 2001;129:504-506.[Medline]
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Abstract
Introduction
