Novel technique for dissection of subcarinal and main bronchial lymph nodes using a laparoscopic transhiatal approach for esophageal cancer

Abstract

Background: Although metastasis to subcarinal or main bronchial lymph nodes (LNs) is common in patients with esophageal cancer, the procedure for their dissection using a laparoscopic transhiatal approach (LTHA) has not been established because of the difficulties associated with this surgery. We developed a novel and simple technique for their dissection using LTHA.

Patients and methods: An abdominal wall sealing device was placed in the upper abdomen, and four ports were inserted. After division of the gastrosplenic ligament by hand-assisted laparoscopic surgery, the esophageal hiatus was opened and carbon dioxide was introduced into the mediastinum. The pericardial adipose tissue was divided, and the pericardium was exposed. The posterior plane of the pericardium was separated and extended, and the anterior side of the subcarinal LNs and bilateral main bronchial LNs were separated. The posterior side of these LNs was then separated. Finally, while lifting these LNs like a membrane, they were resected from the bilateral main bronchi and tracheal bifurcation. The treatment outcomes of 18 patients with esophageal cancer who underwent subcarinal and main bronchial LN dissection by LTHA were compared with those of 19 patients who underwent the procedure by video-assisted thoracic surgery.

Results: The number of resected subcarinal and main bronchial LNs in the two groups was not significantly different. The total operative time and total operative bleeding in the two groups was also not significantly different. Postoperative factors, such as the extubation time after surgery, frequency of postoperative complications, and the length of the postoperative hospital stay in the two groups was not significantly different.

Conclusion: Our surgical procedure resulted in a good surgical view of the mediastinum, and en-bloc dissection of the subcarinal and main bronchial LNs was performed safely.

Keywords: Laparoscopic transhiatal approach; esophageal cancer; subcarinal and main bronchial lymph node dissection.