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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_536_Библиотеки_им_академика_М_И_Перельмана.pdf
Fig. 14.9 Cruroplasty. Close
(a) and schematic view (b)
Fig. 14.10 Gastric conduit
fixed to the specimen and
placed in the left pleural
cavity. Close (a, b) and
schematic views (c, d)
11314 Minimally Invasive Esophagectomy: Ivor Lewis
114 M. Luyer and G. Nieuwenhuijzen
Fig. 14.11 Construction of jejunostomy. Close (a, b) and schematic view (c)
Fig. 14.12 Patient in prone position. Placement of trocars in the right
hemithorax
Fig. 14.13 Pleura along the right lung and azygos vein is divided
Fig. 14.14 Azygos vein is
divided by linear vascular
stapler. Close (a) and
schematic view (b)
11514 Minimally Invasive Esophagectomy: Ivor Lewis
Fig. 14.15 Dissection of the esophagus from the trachea
Fig. 14.16 Cranial
dissection of the esophagus
(a). Thoracic duct is clipped
distally (b)
116 M. Luyer and G. Nieuwenhuijzen
Fig. 14.17 Infracarinal lymphadenectomy. Close (a,b) and schematic view (c)
Fig. 14.18 Transection
of proximal esophagus by
means of linear stapler (a,b)
Fig. 14.19 Stay suture, the stapler line is cut and mucosa and muscu-
lar layers sutured
Fig. 14.20 Charriere 34 Fr at the proximal esophagus
Fig. 14.21 Gastric tube and specimen in the thoracic cavity
11714 Minimally Invasive Esophagectomy: Ivor Lewis
Fig. 14.23 Endo-GIA 30 mm inserted in the gastric tube
Fig. 14.22 Top of the gastric tube is opened
Fig. 14.24 Stapler is inserted in the proximal esophagus, and anasto-
mosis is created
118 M. Luyer and G. Nieuwenhuijzen
Fig. 14.25 Closure of the
opening in two layers by
means of a V-lock
®
(a, b)
Fig. 14.26 Omental wrap around the anastomosis
Fig. 14.27 Approximation of the crura
Fig. 14.28 Retrieval
specimen in a bag. Internal
schematic (a) and external
view (b)
Fig. 14.29 Conventional drain in thoracic cavity and Jackson-Pratt
along the anastomosis
11914 Minimally Invasive Esophagectomy: Ivor Lewis
10. A linear side-to-side anastomosis is created between
distal esophagus and the gastric tube. The stapler line is
cut after placing stay sutures. Mucosa and muscular at
the esophagus are sutured (Fig. 14.19a).
11. A 34 Charriere tube is advanced at the proximal esoph-
agus (Fig. 14.20).
12. Gastric tube is advanced toward proximal esophagus
(Fig. 14.21).
13. At 5 cm from the top of gastric conduit and as close to
vascular pedicle, a small incision is made (Fig. 14.22).
14. The Endo-GIA 30 mm is inserted with its anvil in the
gastric tube (Fig. 14.23).
15. The stapler is advanced guided by the 34 tubes in
the proximal esophagus and the tube retracted. A
side-to-side anastomosis is created (Fig. 14.24).
16. The opening is closed with a V-lock in two planes
(Fig. 14.25a, b).
17. No nasogastric tube is left.
18. Omental wrap is around the anastomosis (Fig. 14.26).
19. Approximate the crura (Fig. 14.27).
20. Retrieve the specimen through a small thoracotomy
(Fig. 14.28a, b).
21. Drains, Jackson-Pratt, and conventional thoracic drain
(Fig. 14.29) are made.
Thoracoscopic Radical Oesophagectomy for Cancer
Harushi Osugi, Kousuke Narumiya and Kenji Kudou
15
15.1 Introduction
Three-field lymphadenectomy has been performed routinely
since mid-1980s in Japan [1], but the extent of lymph node
dissection is still in argument, such as the extended, the
total mediastinal, or the three field [2].
However, the precision of the dissection has not been
discussed because of difficulty in scientific evaluation.
The recurrent laryngeal nerve (RLN) lymph nodes and
tracheobronchial lymph nodes should be dissected precisely, although dissection of these nodes requires substantial effort for surgeons and is associated with the risk
of post-operative complications, especially RLN palsy.
The sensitivity for diagnosing the presence of metastasis in each lymph node station is low [3]; therefore, all the
lymph nodes localized in the supracarinal stations should be
resected and not only the nodes likely being metastasized,
it is no excuse for omitting complete dissection of all stations. Neoadjuvant therapy is widely administered in order
to improve the survival.
The Japanese guideline recommended neoadjuvant
chemotherapy for the patients with resectable tumour and
nodal involvement, according to the result of JCOG9907
study [4]. Therefore, Japanese surgeons are privileged to
perform oesophagectomy on treatment with or without previous radiotherapy patients.
In this chapter, microanatomy, which is essential for
precise dissection through thoracoscopy, will be showed in
patients without mediastinal fibrosis caused by neoadjuvant
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_15) contains
supplementary material, which is available to authorized users.
H. Osugi (*) · K. Narumiya · K. Kudou
Department of Surgery, Institute of Gastroenterology, Tokyo
Women’s Medical University, Sinjuku-ku, Japan
e-mail: Osugiharushi1229@gmail.com
treatment, especially radiotherapy. As the left lateral position has been the preferred approach since introduction of
thoracoscopic oesophagectomy in 1995 at our institute [5],
the figures are obtained in the left lateral position (the upper
and left is the ventral and cranial, respectively). So, in order
to adapt the monitor images in the prone position, the figures should be rotated 90° to the right.
15.2 Thoracoscopic Mediastinal Dissection
15.2.1 Surgical Anatomy of Mediastinum with Reference to the Oesophagus
15.2.1.1 Layer Structures and Principle
of Dissection in the Mediastinum
Figure 15.1 demonstrates the layer structure of the mediastinum cranial to the aortic arch. The most outer structure
under the mediastinal pleura is the neural branches. The
sympathetic branches from the right trunk dominate over
the left and encase the oesophagus and thoracic duct. Black
heavy arrows indicate our dissecting layer for total mobilization in the upper mediastinum.
Figure 15.2 demonstrates the layer structure of the mediastinum caudal to the pulmonary hilum. The most outer
structure under the mediastinal pleura is the neural branches
from the sympathetic trunks, and the right branches dominantly encase the oesophagus. Almost all structures divided
during the mediastinal mobilization run transversally, except
the oesophagus, vagal nerves, and thoracic duct. Therefore,
mobilization should be done transversally or orthogonally to
the aorta and tracheobronchus. Identifying structures under
magnified view, the neural branches are divided without
sealing to avoid abuse use of energy devices and unnecessary tissue damage. Under magnified view, the epineurium
of the recurrent and vagal nerve can be identified easily as
shiny fine membrane with fine vessels running longitudinally
© 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_15
121
122 H. Osugi et al.
Fig. 15.1 Illustration of the anatomy, cranial to the aortic arch. Black
heavy arrows indicate dissecting layers for the total mobilization in the
upper mediastinum. The sympathetic branches from the right trunk
dominate over the left and encase the thoracic duct. Abbreviations: rmp:
right mediastinal pleura, lmp: left mediastinal pleura, rst: right trunk of
the sympathetic nerve (b1: the branch between the oesophagus and thoracic duct and the landmark of dissection when the thoracic duct is preserved, b2: the branches encase the thoracic duct and is divided for total
mediastinal mobilization), lst: left trunk of the sympathetic nerve, az:
azygos vein, td: thoracic duct, rsa: right subclavian artery, cs: cardiac
branches of the sympathetic nerve from the cervical ganglion, lrn: left
recurrent nerve, ln: nodes along the left recurrent nerve, vn: vessels of
the left recurrent nodes (commonly present in front of the node)
Fig. 15.2 Illustration of the anatomy, caudal to the pulmonary hilum.
Abbreviations: rst: right trunk of sympathetic nerve, lst: left trunk of
sympathetic nerve, bsn: branches from trunk of sympathetic nerve,
td: thoracic duct, rmp: right mediastinal pleura, lmp: left mediastinal
pleura, pc: pericardium, ln: lymph nodes along the aorta and oesophagus (the most left nodes can be dissected through right transthoracic
approach, present at the angle between the fibrous membrane on the
aorta and left mediastinal pleura)
(Fig. 15.3). As no vessel penetrates the epineurium in the
dissection field, exposing the epineurium is the ideal layer
of dissection. Under the magnified view, the structure of
lymph node becomes obvious. Histologically, the lymph
node has only the afferent lymphatics on the convex capsule
(Fig. 15.4), and, only at the hilum, receives the artery and the
vasoacting unmyelinated nerve and gives off the vein and
efferent lymphatic vessel (Fig. 15.5). These hilar structures
fix the lymph nodes. Understanding of direction of the fixation does facilitate nodal dissection (Figs. 15.6 and 15.7).
15.3 Description of the Surgical Technique (see Video 15.1)
15.3.1 Dissection of the Right Recurrent
Nodes
Firstly, the mediastinal pleura is incised along the right
vagal nerve, the right subclavian artery, and ventral margin of the vertebra. Dividing the tracheoesophageal artery,
Fig. 15.3 Epineurium of the left recurrent nerve. Under magnified
view, the glossy appearance with the fine vessels running longitudinally is recognized. There is no vessel that penetrates the epineurium
in the dissection field. Abbreviations: lrn: left recurrent nerve, st:
stump of the branch
arising from the right subclavian artery and running on the
right side of the oesophagus to the anterior aspect of the trachea, at the anterior edge of vertebra, the fatty tissue consisting of the recurrent nodes becomes mobile. Then, the
Fig. 15.4 Magnified view of lymph nodes with anthracosis and its
vessels. Abbreviations: v: fine vein of the lymph node, al: afferent
lymphatic of the lymph node. Under magnified view, even the thickness of the vein and lymphatic can be comparable
epineurium of vagal nerve is exposed, and the right recurrent nerve is identified at its recurring point (just caudal to
the right subclavian artery). The dissection along the recurrent nerve is carried out by exposing its epineurium and
dividing the oesophageal branches (commonly four or five
are divided) up to the caudal border of the right lobe of the
thyroid gland. The nodes present dorsal to the recurrent
nerve. The recurrent nerve should be carefully differentiated
12315 Thoracoscopic Radical Oesophagectomy for Cancer
from the sympathetic nerve and from the cervical ganglion
(Fig. 15.8). The sympathetic nerve runs along the right
subclavian artery, through the arch of the recurrent nerve,
and to the frontal aspect of the trachea, and forms V shape
together with the vagal nerve in contrast to the recurrent
nerve that forms a U shape. In some patients, the tracheoesophageal artery divides at proximal site of the subclavian
artery, near the recurrent nerve (Fig. 15.8). In these patients,
care should be taken not to injure the artery, so to avoid
incurring palsy of the nerve (Videos 15.1–15.5).
15.3.2 Mobilization of the Dorsal Aspect of the Oesophagus
Cranial to the aortic arch, the dorsal aspect of the oesophagus is rather avascular and anatomically simple. However,
there can be three planes of dissection according to the right
sympathetic branches. When the thoracic duct is preserved,
dissection should be performed along b1 in Fig. 15.1. For
the total mediastinal mobilization along b2 in Fig. 15.1, the
thoracic duct is excised and the branches of the left sympathetic trunk are cut, and then the left mediastinal pleura
is exposed (Fig. 15.9). The azygos arch is mobilized and
divided following double ligation. The ligated ends are
retracted through the chest wall ventrally and dorsally to
enhance mediastinal exposure. The pleura is then incised
Fig. 15.5 Illustration of histology of the lymph node. A black arrow indicates the vasoacting unmyelinated nerve. The hilar structures fix the
node