An original technique for lymph node dissection along the left recurrent laryngeal nerve after stripping the residual esophagus during video-assisted thorocoscopic surgery of esophagus

Abstract

Background: A clear operative view of the middle and lower mediastinum is possible in prone position during video-assisted thorocoscopic surgery of esophagus (VATS-E), but the working space in the upper mediastinum is limited and lymph node dissection along the left recurrent laryngeal nerve (RLN) is difficult in this position.Methods: Esophagectomy and lymph node dissection are performed for pneumothorax by maintaining CO 2 insufflation in the prone position. Working space in the left upper mediastinal area for lymph node dissection around RLN is limited in this position. To create space, the residual esophagus is stripped in the reverse direction and retracted toward the neck after the stomach tube is removed through the nose. Lymph node dissection is performed after stripping the residual esophagus. Results:We could obtain a clear operative field in the upper left mediastinum by stripping the residual esophagus in the prone position, enabling safe and straightforward lymph node dissection along the left RLN. The rate of permanent RLN paralysis was 1.2%.Conclusions: Lymph node dissection along the left RLN after esophageal stripping is possible in the prone position during VATS-E. left mediastinum with the patient in the prone position, enabling safe and straightforward lymph node dissection along the left RLN. We would like to describe our lymph node dissection method along the left RLN in this report. Methods Patient selection and workup (Table 1)One hundred patients with esophageal carcinomas underwent video-assisted thorocoscopic surgery of esophagus (VATS-E) (27 in left lateral position and 73 in prone position). At first VATS-E in left lateral position, and then the prone position were selected for patients with superficial esophageal carcinoma from 2005. VATS-E in the prone position is indicated for all patients with resectable esophageal carcinomas with or without chemotherapy or chemoradiotherapy since 2011. Equipment preferenceElectrical devices used for VATS-E in the prone position were SonoSurg (Olympus Medical Systems, Tokyo, Japan) or LigaSure Maryland jaw sealer (Covidien, Mansfield, MA, USA). Single-port devices were ENDOPATH XCEL ® Trocars (Ethicon, Cincinnati, OH, USA): three ports: 5 mm (one port long and three ports short) and one port: 12 mm (short).Retractors: End retract mini (Covidien, Mansfield, MA, USA).Others: 5 mm flexible laparoscope (Olympus Medical Systems, Tokyo, Japan); Endoscopic scissors and forceps. Pre-operative preparationGeneral anesthesia with one lung ventilation was performed using a double lumen endotracheal tube. An epidural anesthesia tube was inserted to relieve pain in the upper abdomen. The patient was placed in a semi-prone position with a "magic bed" (or vacuum fixing bed) and a shoulder roll that was placed under the axillary. Procedure Position and port sitesThe patient is immobilized in the semi-prone position. For an esophagectomy, the patient is rotated from the semiprone position to the prone position. For an emergency thoracotomy, the patient is rotated ...

Review of different approaches of the left recurrent laryngeal nerve area for lymphadenectomy during minimally invasive esophagectomy

“…Japanese surgeons have described two methods after esophageal division in order to visualize the left upper mediastinum: the "stripping method" and the "bascule method". In the first method, the proximal esophagus (and the nasogastric tube) once divided, is stripped by pulling the nasogastric tube in the reverse direction and retracted toward the neck (Figure 1) (12,13). In the second method, the proximal esophagus is kept attached to the left upper mediastinum and after division the tissue including the LRLN and lymph nodes remain attached to the proximal part of the esophagus.…”

Lymph Node Dissection along the Recurrent Laryngeal Nerve in Video-Assisted Thoracoscopic Surgery (VATSE) for Esophageal Squamous Cell Carcinoma

“…The wide operative field of left upper mediastinum is possible using this stripping technique. Lymph node dissection is performed after stripping the residual esophagus [28,29] (Figure 4A). Moreover, working space is created by compressing the right main bronchus or retracting the trachea using a retractor.…”

“…This original technique of lymphadenectomy along the left RLN has been performed in 54 patients in the prone position VATS-E. The rate of transient recurrent laryngeal nerve palsy is 17.2%, but permanent palsy is only 1.2% [29].…”