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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
Fig. 11.15 Esophageal
dissection: Anterior plane.
Close view (a–d) and
schematic view (e)
8111 Transmediastinal Approach for Esophageal Cancer …
Dissect the foamy loose connective tissue induced by CO2
insufflation bluntly (Fig. 11.13a).
Thoracic duct (TD) is seen below the dissected plane
through a membrane (Fig. 11.13b).
TD adheres closely to the esophagus near the azygos arch
(Fig. 11.13c). Pay attention to TD injury!
– Divide the remaining vessels (esophageal A and V)
after blunt dissection (Fig. 11.13d).
– Expose bilateral pleurae. Dissect the space as far as
the device reaches.
– Maryland-type Ligasure (44 cm length) is best suit-
able for transcervical procedure. Articulating-type
Enseal (45 cm length) is also suitable to dissect the
deeper space and the left side of the descending aorta.
Esophageal dissection: Left side (Fig. 11.14).
Points of attention:
Create a layer including the autonomic nerves and left tra-
cheoesophageal artery by posterior and anterior dissection (Fig. 10.14a).
Then, divide the layer along the vascular sheath of CCA
and SCA until reaching the aortic arch (Fig. 11.14b).
82 H. Fujiwara et al.
Fig. 11.16 Esophageal
dissection: Right side (a–d)
The bronchial artery arises from the aorta (distal arch
to proximal descending aorta), and the main trunk
or branches often run across the anterior plane of the
esophagus.
Divide the branches of the left bronchial artery or main
trunk of the right bronchial artery during esophageal dis-
section over the aortic arch (Fig. 11.14c).
Expose the left main bronchus and confirm the left side of
tracheobronchial, or subaortic arch lymph nodes (106bL)
are dissected (Fig. 11.14d, e).
Esophageal dissection: Anterior plane (Fig. 11.15).
Next, moving to the right side of the esophagus, the
lymph nodes along the left RLN were separated from the
tracheal wall until the tracheobronchial angle was exposed,
and the anterior plane of the lymph nodes was exposed until
they were separated from the aortic arch.
Points of attention:
Dissect the right side of No. 106recL lymph nodes by
exposing the tracheal wall until reaching the left tracheo-
bronchial angle (Fig. 11.15a).
Divide the tracheobronchial ligament along on the esopha-
geal wall, avoiding the esophagus to the left. Take care
not to injure the tracheal membrane due to the membrane traction (Fig. 11.15b).
Identify the pulmonary artery below the aortic arch, and
expose the right side of No. 106tbL lymph nodes
(Fig. 11.15c).
Separate No. 106recL lymph nodes from the aortic arch,
and identify the left RLN. The cardiac N (cardiac
branch of sympathetic N) often runs parallel to the RLN
(Fig. 11.15d).
Skeletonize the left RLN root as much as possible by divid-
ing the cardiac N and the bronchial artery.
Esophageal dissection: Right side (Fig. 11.16).
Then, while avoiding the esophagus using a retractor,
the esophago-tracheal ligament was divided, and the paraesophageal lymph nodes were dissected along the right
mediastinal pleura until exposing the azygos arch, while the
RBA was skeletonized.
After dividing the esophageal branches of the right
vagal nerve, the posterior wall of the esophagus was further dissected along the azygos vein, as far as the device
reached.
The right plane of the subaortic arch lymph nodes was
exposed by separation from the left main bronchus and the
pulmonary artery.
Fig. 11.17 Subcarinal
lymph nodes dissection (a–d)
8311 Transmediastinal Approach for Esophageal Cancer …
Points of attention:
Avoiding the esophagus to the left, create an opening to the
space by the posterior dissection (Fig. 11.16 a).
Exposing the right pleura and tracheal membrane, dissect
the para-esophageal lymph nodes (No. 105) along the
pleura and trachea (Fig. 11.16b).
Expose the azygos arch sufficiently and identify the right
vagus nerve inside the azygos arch, and then dissect the
esophagus further dividing the esophageal branches of
the nerve (Fig. 11.16c).
When you see the right bronchial artery inside the azygos
arch, divide the esophageal branches and dissect the
lymph nodes around the artery (the deepest No. 105)
(Fig. 11.16d).
Subcarinal lymph nodes dissection (Fig. 11.17).
Points of attention:
Following the right-side esophageal dissection, the
subcarinal (No. 107) lymph nodes including bilateral main bronchial (No. 109R/L) lymph nodes are
dissected.
Dissect the layer between the esophagus and the left main
bronchus and on the bronchial wall. Then, you can easily
see the pericardium and reach the anterior plane of the
subcarinal lymph nodes (Fig. 11.17a).
Expose the pericardium to the right to dissect the left side
of No. 107 lymph nodes.
Exposing the right vagus nerve toward the periphery, first
identify the inside margin (cartilages) of the right main
bronchus, and then, expose the margin as much as pos-
sible to demarcate No. 109R lymph nodes.
After that, dissect No. 107 and 109R lymph nodes com-
pletely from the tracheal bifurcation and pericardium,
with grasping and pulling the lymph nodes down
(Fig. 11.17b).
To dissect the lymph nodes without bleeding, identify and
divide the bronchial artery (main trunk or branches)
feeding the lymph nodes.
After dissecting No. 107 and 109R lymph nodes
(Fig. 11.17c), dissect the proximal part of No 109
L lymph nodes along the left main bronchus to the
periphery.
After moving to the left side of the esophagus, dissect the
distal part of No 109L lymph nodes until exposing the
left pleura and the left pulmonary vein (Fig. 11.17d, final
view after completing No. 109L dissection).
84 H. Fujiwara et al.
Isolation of the left RLN (Fig. 11.18).
Following esophageal mobilization, the lymph nodes
along the left RLN were separated from the left RLN
trunk using endoscopic scissors, with the nodes remaining
attached to the esophagus.
First, the nerve trunk was exposed along the anterior
plane, and then, the lymph nodes were retracted to the left,
through beneath the nerve trunk, and separated by dividing
the attachment to the nerve trunk.
Finally, the subaortic arch lymph nodes were dissected
by dividing the attachment to the nerve trunk.
Points of attention:
After esophageal dissection, the left RLN is isolated
sharply with scissors to dissect No. 106recL and 106tbL
lymph nodes. First, expose the anterior plane of the left
RLN until the aortic arch (Fig. 11.18a).
Pulling No. 106recL lymph nodes to the left through
beneath the nerve, separate the lymph nodes from the
nerve sharply dividing the nerve branches one by one
(Fig. 11.18b).
Avoiding the aorta arch gently by the retractor to expand
the subaortic arch view, divide the remaining attachment of
NO. 106tbL lymph nodes to the nerve (Fig. 11.18c).
To avoid bleeding from the bronchial artery branches
during No. 106 tbL dissection, clip and divide the vessels
sharply with scissors in case near the nerve or divide them
with an energy device in case far from the nerve.
Final view after completing No. 106recL and 106tbL
lymph nodes dissection is shown in Fig. 11.18d, e.
11.2.3 Right Cervical Procedure (Fig. 11.19)
The lymph nodes along the right RLN were dissected under
direct vision from the right cervical incision.
The lateral halves of the anterior cervical muscles were
divided to expose the anterior plane of the lymph nodes.
Then, the sternocleidomastoid muscle and common
carotid artery were retracted to the right to expose the posterior plane of the lymph nodes.
Following exposure of the right RLN trunk, the attachment of the lymph nodes to the tracheal wall and the nerve
trunk was carefully divided by scissors; then, the lymph
nodes were resected.
Points of attention:
No. 106recR lymph nodes are present in the shallow
mediastinum near the neck and can be dissected under
direct vision, but it is sometimes difficult to identify the
right RLN or dissect the lymph nodes adequately.
Intraoperative monitoring with NIM response 3.0 is
highly useful to identify the right RLN and safely perform
the lymph node dissection (Fig. 11.19a).
To secure adequate surgical field, the sternocleidomastoid muscle and common carotid artery are avoided to the
outside, and the thyroid is avoided to the inside after dividing the lateral halves of the strap muscles. Take care not to
press the RLN with a retractor.
First, dissect the posterior plane of No. 106recR lymph
nodes; then, dissect the anterior plane by dividing the
nerve branches to the lymph nodes sharply with scissors
(Fig. 11.19b).
Dissect the deep part of the lymph nodes by pulling the
lymph nodes gently with forceps. At that time, take care not
to injure the nerve trunk (Fig. 11.19c). The nerve trunk may
be bent by pulling the branches.
Finally, divide the attachment to the tracheal wall to
complete the lymph node dissection (Fig. 11.19d).
11.2.4 Transhiatal procedure (Figs. 11.20
and 11.21)
Before the laparoscopic procedure, the greater and lesser
omenta were divided under direct vision through the midline incision. Abdominal and transhiatal procedures were
performed by carbon dioxide insufflation (10 mmHg). The
operator inserted his left hand into the abdominal cavity
through a Lap Disc (Ethicon) attached to the midline incision to control the stomach during the abdominal procedure, and to control the esophagus and the liver for hiatal
expansion during the transhiatal procedure. After dividing the gastro-splenic ligament, the esophageal hiatus
was opened along the left crus, to enter the mediastinum
(Fig. 11.20).
Anterior plane dissection. First, following exposure of
the pericardium, the anterior plane of the para-esophageal
tissues was dissected along the pericardium. After exposing
the left inferior pulmonary vein and avoiding it anteriorly
with a retractor, the left main bronchial lymph nodes were
exposed, separated from the left main bronchus from the
periphery to the carina, and further extended to the right to
expose the anterior plane of the subcarinal and right main
bronchial lymph nodes until the right main bronchus was
exposed.
Posterior plane dissection. Next, returning to the hiatus, the aortic wall was exposed, and the posterior plane of
the para-esophageal tissues was dissected along the aorta
toward the aortic arch, with division of the esophageal
branches of the aorta. The posterior plane of the transhiatal
dissection was then opened to the space dissected using a
cervical approach at the level below the left main bronchus,
and the posterior dissection was further extended to the
right until the azygos vein and the right mediastinal pleura
were exposed.
Fig. 11.18 Isolation of the
left RLN (a–e) and transversal
schematic view (f)
8511 Transmediastinal Approach for Esophageal Cancer …
Left-side dissection. Then, the para-esophageal tissues
with the para-aortic lymph nodes, dissected using anterior
and posterior approaches, were divided along the left mediastinal pleura until the left main bronchus was reached.
Consequently, the left mediastinal lymph nodes, including
the para-aortic to subcarinal and left main bronchial lymph
nodes, were dissected en bloc.
Right-side dissection. Then, following complete mobi-
lization of the stomach by dividing the left gastric artery
and vein with dissection of the abdominal lymph nodes, the
right para-esophageal tissues were divided along the right
mediastinal pleura until reaching the right main bronchial
lymph nodes, which were then separated from the right
main bronchus. Consequently, the right mediastinal lymph
nodes, including the right main bronchial lymph nodes,
were dissected en bloc.
Points of attention:
Dissect the anterior plane of the esophagus, exposing
the pericardium; then, you can easily see the opening to the
space dissected from the cervical side (Fig. 11.21a).
Final view after completing the anterior dissection is
shown in Fig. 11.21b.
Dissect the posterior plane of the esophagus, exposing
the aorta, and then, you can readily reach the space dissected from the cervical side (Fig. 11.21c).
86 H. Fujiwara et al.
Fig. 11.19 Right cervical
procedure (a–d)
Fig. 11.20 Procedure with
(a) or without hand assistance
(b)
After anterior and posterior plane dissections, dissect
the lymph nodes along the aorta (No. 112) by dividing the
attachment to the left pleura (Fig. 11.21d).
Final view after completing the division along the left
pleura is shown in Fig. 11.21e.
After moving to the right side of the esophageal hiatus,
divide the attachment along the right pleura (Fig. 11.21f).
Final view after completing the division along the right
pleura is shown in Fig. 11.21g.
Final view after completing the transhiatal procedure is
shown in Fig. 11.21h.
11.2.5 Esophageal Reconstruction
Finally, the cervical esophagus was transected through
the left cervical incision, and the esophagus, with the
total mediastinal lymph nodes dissected en bloc, was
Fig. 11.21 Transhiatal
procedure (a–h)
8711 Transmediastinal Approach for Esophageal Cancer …
88 H. Fujiwara et al.
transhiatally removed. A stomach roll was pulled up
through a retrosternal route and anastomosed to the esophagus in the left neck.
A J-VAC suction drain (Ethicon) was placed in the left
cervical wound. An enteral nutrition tube was inserted
through the upper abdominal wall and placed into the
jejunum through the stomach roll. Neither a thoracic nor
an abdominal drain was placed. No nasogastric tube was
placed.
11.2.6 Postoperative Management
The patient was extubated in the operation room, entered
the ICU, and then returned to the general ward on postoperative day 1. As this operation does not involve the placement of a thoracic drain, pleural effusion is often detected
in either the right or the left pleural cavity by a chest X-ray,
and removed by a pleural tap once or twice. The left cervical drain is removed on postoperative day 5. Food intake
was started after a swallowing test and vocal cord evaluation by using a laryngoscope after postoperative day 7. The
patient was usually discharged from hospital, free from
enteral and parenteral nutrition support, 2–3 weeks after the
operation.
11.3 Conclusions
The success of video-assisted radical esophagectomy
without thoracotomy is determined by whether or not
an accurate and sufficient lymphadenectomy in the deep
mediastinum is achieved. The elements needed to achieve
this include understanding of the mediastinal anatomy specific for cervical and transhiatal procedures; stable expansion of the mediastinal entry using cervical and transhiatal
approaches; adequate expansion of the deep mediastinal
space; appropriate use of an energy device; and performing according to the standardized procedure. Based on these
elements, improving surgical experience and skills is the
most important way to achieve the success of this operation.
A single-port technique provides a favorable expansion
of the mediastinal space by carbon dioxide insufflation and
improves the visibility and handling in the deep mediastinum around the aortic arch, allowing for en bloc lymphadenectomy in the upper mediastinum including the subaortic
arch lymph nodes. In addition, a hand-assisted laparoscopic
transhiatal procedure allows for en bloc lymphadenectomy
in the middle and lower mediastinum including the subcarinal and bilateral main bronchial lymph nodes. Cervical
and transhiatal procedures were performed safely and carefully under video-assisted magnified vision according to the
standardized procedure with an appropriate operative field
expansion using retractors.
Single-port MATHE is feasible as a novel minimally
invasive surgery for esophageal squamous cell carcinoma
(ESCC) or thoracic esophageal cancer.
References
1. Bumm R, Hölscher AH, Feussner H, et al. Endodissection of the
thoracic esophagus. Technique and clinical results in transhiatal
esophagectomy. Ann Surg. 1993;218:97–104.
2. Tangoku A, Yoshino S, Abe T, et al. Mediastinoscope- assisted
transhiatal esophagectomy for esophageal cancer. Surg Endosc.
2004;18:383–9.
3. Feng MX, Wang H, Zhang Y, et al. Minimally invasive esophagec-
tomy for esophageal squamous cell carcinoma: a case-control study
of thoracoscope versus mediastinoscope assistance. Surg Endosc.
2012;26:1573–8.
4. Tachimori Y, Ozawa S, Numasaki H, et al. Efficacy of lymph node
dissection by node zones according to tumor location for esophageal squamous cell carcinoma. Esophagus. 2016;13:1–7.
5. Udagawa H, Ueno M, Shinohara H, et al. The importance of
grouping of lymph node stations and rationale of three-field lymphoadenectomy for thoracic esophageal cancer. J Surg Oncol.
2012;106:742–7.
6. Fujiwara H, Shiozaki A, Konishi H, et al. Hand-assisted laparo-
scopic transhiatal esophagectomy with a systematic procedure
for en bloc infracarinal lymph node dissection. Dis Esophagus.
2016;29:131–8.
7. Fujiwara H, Shiozaki A, Konishi H, et al. Single-Port
Mediastinoscopic Lymphadenectomy Along the Left Recurrent
Laryngeal Nerve. Ann Thorac Surg. 2015;100:1115–7.
8. Fujiwara H, Shiozaki A, Konishi H, et al. The left cervical pro-
cedure using a single-port mediastinoscopic technique. Asvide
2016;3:290. https://www.asvide.com/articles/1052
9. Fujiwara H, Shiozaki A, Konishi H, et al. The transhiatal procedure
using a hand-assisted laparoscopic technique. Asvide 2016;3:291.
https://www.asvide.com/articles/1053
Laparoscopic Transhiatal Resection for Distal Esophageal and Gastro-Esophageal Junction Cancer
Miguel A. Cuesta and Donald L. van der Peet
12
12.1 Introduction
Conventional surgical treatment of esophageal cancers
through thoracotomy is characterized by a high rate of complications, especially pulmonary infections. Transhiatal
approach for distal esophageal and GEJ esophageal cancers has been designed by Orringer and Sloan [1] in order
to reduce these complications by avoiding the thoracic
route. Disadvantage of this approach is the no possibility to perform an adequate mediastinal lymphadenectomy.
The HIVEX trial [2] has compared in a randomized setting, without the use of neoadjuvant therapy, the transhiatal
versus transthoracic approach for distal and GEJ types 1
and 2 Siewert tumors. In this study, a trend is found for a
better survival for the transthoracic approach in type 1
GEJ tumors, with no differences in survival for the type 2.
Current indications for this transhiatal approach, conventional or laparoscopically are these GEJ tumors and the distal esophageal cancers in fragile patients [3–6].
12.2 Description of the Operative Technique
The conventional operation technique described by
Orringer and Sloan [1] is performed laparoscopically [4, 5]
(Video 12.1).
1. The patient is positioned in the supine position with the
legs in the French position and the neck extended with
exposure of the left side. The operating surgeon stands
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_12) contains
supplementary material, which is available to authorized users.
M. A. Cuesta (*) · D. L. van der Peet
Department of Surgery, Amsterdam UMC, Amsterdam,
The Netherlands
e-mail: ma.cuesta@amsterdamumc.nl
between the legs of the patient looking at two monitors
placed at shoulder level of the patient. Two assistants
stand on both sides of the patient, with the nurse on the
right side of the surgeon.
2. A pneumoperitoneum is created by a 10-mm incision
halfway between the xiphoid and the umbilicus on the
left side of the middle line. The camera is introduced
through this trocar, and four other trocars are placed in
the upper abdomen (Fig. 12.1).
3. Abdominal and local inspection at the hiatus takes
place. After displacement of the lateral segments of
the left hepatic lobe and caudal traction of the stomach
(Fig. 12.2a, b), a transhiatal dissection of the esophagus
is laparoscopically performed in the plane between the
pericardial sac, aorta, and both pleurae. For this part
of the operation, a sealing device is used. After division of the hepatogastric ligament (pars flaccida) and
the most proximal short vessels, the space between the
right crus and the esophagus is gently opened in order
to dissect the esophagus free and place a sling around it
(Fig. 12.3a, b). In the case of junction tumors, a ring of
the hiatus muscle is resected. The sling, placed around
the esophagus, will permit traction of the esophagus in
the caudal direction (Fig. 12.4a, b).
4. The hiatus is enlarged by dividing the anterior part
with the division of the phrenic vein by means of the
LigaSure device according to Pinotti [3] (Fig. 12.5a, b).
Anteriorly dissection is performed in an avascular
plane in the anterior mediastinum with visualization of
the pericardial sac and pulmonary vein (Figs. 12.6a, b
and 12.7).
5. On the right side of the esophagus, the aorta is
approached at the level of the hiatus and in an avascular plane dissected free as high as possible in the posterior mediastinum (Fig. 12.8a–d).
6. Dissection proceeds up to the level of the carina, in
which the lymph nodes can be visualized but not
resected (Fig. 12.9).
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_12
89
90 M. A. Cuesta and D. L. van der Peet
Fig. 12.1 Position of patient
and trocar placement
Fig. 12.2 Traction and
exposition of the gastroesophageal junction. Close
(a) and schematic view (b)
Fig. 12.3 After opening the
hepatogastric ligament, the
space between the right crus
and the esophagus is opened.
Close (a) and schematic
view (b)