Abstract
Mediastinal lymphadenectomy is a crucial part of minimally invasive esophagectomy, and requires transthoracic operation, which is a crucial independent risk factor for the incidence of pulmonary complications. Conventionally, non-transthoracic esophagectomy was often achieved by mediastinoscope-assisted laparoscopic transhiatal surgery. Because of the small space, the lymphadenectomy could be only performed partially under mediastinoscope in upper mediastinal. We propose a new approach of lymphadenectomy along bilateral recurrent laryngeal nerve under mediastinoscopy through one left-neck incision.
Methods
A 3-cm incision paralleling the clavicle was made at 2-cm from the supraclavicular region in the left neck. After established pneumomediastinum (10-12 mmHg carbon dioxide), esophagectomy begins to perform over the aortic arch to the level of lower edge of the left main bronchus, and the lymphadenectomy along the left RLN has also accomplished during this process. At the level of lower edge of the right subclavian artery (RSA), between the trachea and the esophagus, the instruments could get accessed to the right RLN. The lymphadenectomy could get accomplished up to 2-cm at the upper edge of the RSA.
Results
The mean age of 56 esophageal squamous cell cancer patients was 67.4 years, 46 males and 10 females. Tumor location: middle thoracic, 31 patients, lower thoracic, 23 patients. Preoperative TNM staging: T1b was 10 cases, T2 was 35 cases, and T3 was 11 cases. The median number of mediastinal LNs removed was 17 (9 to 23); 6 (2 to 9) along the left RLN; 3 (1 to 6) along the right RLN. 7 patients (12.5%) developed RLN palsy. Postoperative laryngoscopy showed that all of the 7 RLN palsy were left side, none of them appeared at 3 months postoperation.
Conclusion
This approach enables the lymphadenectomy along bilateral RLN through one left neck incision. During the operation, the upper mediastinal LNs along the bilateral RLN were clearly revealed and en bloc excised. Meanwhile, the bilateral RLN were fully exposed and protected during the procedure. Compared with the previous surgical methods,this procedure is less invasive, and the bilateral RLN could be exposed much clearer. It would provide a novel approach for the minimally invasive esophagectomy, especially lymphadenectomy.
Continuous intraoperative vagus nerve stimulation for monitoring of recurrent laryngeal nerve during minimally invasive esophagectomy
