Middle and lower esophagectomy preceded by hand-assisted laparoscopic transhiatal approach for distal esophageal cancer

Abstract

Respiratory morbidity is the most frequent complication following an esophagectomy. This study was designed to determine the efficacy of middle and lower esophagectomies preceded by the hand-assisted laparoscopic transhiatal approach (LTHA) regarding the perioperative outcomes of distal esophageal cancer. The esophageal hiatus was opened and carbon dioxide was introduced into the mediastinum. Dissection of the distal esophagus was performed up to the level of the tracheal bifurcation. En bloc dissection of the posterior mediastinal lymph nodes was performed using the LTHA. Subsequently, a small thoracotomy (10 cm) was performed to divide the thoracic esophagus and allow middle mediastinal lymphadenectomy. Finally, reconstruction via the posterior mediastinal route with a gastric tube and anastomosis in the thoracic cavity were performed using a circular stapler. The treatment outcomes of 10 patients who underwent LTHA-preceded middle and lower esophagectomy were compared to those of 11 patients treated without prior LTHA (thoracotomy, 20 cm). The total operative time, the duration of one-lung ventilation and total operative blood loss were significantly decreased in the LTHA group. The number of resected lymph nodes did not differ significantly between the two groups. Postoperative respiratory complications occurred in 10.0% of patients treated with, and 36.3% of those treated without LTHA. The extubation time following surgery, the duration of thoracic drainage and postoperative hospital stay were significantly decreased by this method. In conclusion, middle and lower esophagectomies preceded by LTHA provides a good surgical view of the posterior mediastinum, markedly shortens the duration of one-lung ventilation and improves the perioperative outcome.

Keywords: distal esophageal cancer; laparoscopic transhiatal approach.

Figure 1.

(A) Intraoperative view of the trocars and incision locations on the abdomen. A lap disc (regular) was placed in the upper abdomen. Three 12-mm ports were inserted, one in each flank and one in the left hypochondrium; one 5-mm port for the videoscope was inserted in the lower abdomen. (B) The esophageal hiatus was divided and carbon dioxide was introduced into the mediastinum. Dissection of the anterior sides of the posterior mediastinal lymph nodes was performed with the EnSeal device. (C) The anterior and posterior sides of the posterior mediastinal lymph nodes were resected: while lifting up these lymph nodes like a membrane, they were cut along the borderline of the left mediastinal pleura. (D) The posterior mediastinal lymph nodes (thoracic paraaortic and left pulmonary ligament lymph nodes) were dissected en bloc.

Figure 2.

(A) The dissection of the posterior mediastinal lymph nodes was extended towards the caudal side from the crura of the diaphragm to the celiac artery. (B) The left gastric artery was exposed from the left side and the lymph nodes along the left gastric artery were dissected. (C) An incision was made in the right mediastinal pleura and was extended to the level of the arch of the azygos vein. (D) Reconstruction via the posterior mediastinal route with a gastric tube and anastomosis in the thoracic cavity were performed using a circular stapler (CDH25) via the thoracic approach.