Mediastinoscopic Subaortic and Tracheobronchial Lymph Node Dissection With a New Cervico-Hiatal Crossover Approach in Thiel-Embalmed Cadavers

The use of mediastinal surgery for minimally invasive esophagectomy (MIE) has been proposed; however, this method is not performed as radical surgery because it has been thought to be impossible to perform complete upper mediastinal dissection, including the left tracheobronchial lymph nodes (106tbL). We herein describe a new method for performing complete dissection of the upper mediastinum. We developed a method for performing complete mediastinoscopic esophagectomy as radical surgery via the bilateral transcervical and transhiatal approach in 6 Thiel-embalmed human cadavers. The lower and middle mediastinal lymph nodes are dissected via the transhiatal approach. The dorsal side of the left recurrent nerve is dissected up to the aortic arch and left recurrent nerve lymph nodes (106recL) are dissected under pneumomediastinum. Next, the right recurrent nerve lymph nodes (106recR) are dissected. The cartilage of the left main bronchus is dissected and pushed downward, thereby obtaining a good view between the aortic arch and left main bronchus via the transhiatal approach. The 106tbL lymph nodes are dissected until the aortic arch is reached. Simultaneously, the lymph nodes are dissected via a right cervical incision. This method is termed the “cross-over technique.” We herein demonstrated that the upper mediastinal lymph nodes, including the 106tbL nodes, can be dissected using the bilateral transcervical and transhiatal approach under pneumomediastinum and named this method “mediastinoscopic esophagectomy with lymph node dissection” (MELD). MELD is therefore considered to be a useful modality based on our experience with Thiel-embalmed human cadavers.