Abstract
BackgroundDuring esophageal dissection and lymphadenectomy of the upper mediastinum by thoracoscopy in prone position, we observed a complex anatomy in which we had to resect the esophagus, dissect vessels and nerves, and take down some of these in order to perform a complete lymphadenectomy. In order to improve the quality of the dissection and standardization of the procedure, we describe the surgical anatomy and steps involved in this procedure.MethodsWe retrospectively evaluated twenty consecutive and unedited videos of thoracoscopic esophageal resections. We recorded the vascular anatomy of the supracarinal esophagus, lymph node stations and the steps taken in this procedure. The resulting concept was validated in a prospective study including five patients.ResultsSeventy percent of patients in the retrospective study had one right bronchial artery (RBA) and two left bronchial arteries (LBA). The RBA was divided at both sides of the esophagus in 18 patients, with preservation of one LBA or at least one esophageal branch in all cases. Both recurrent laryngeal nerves were identified in 18 patients. All patients in the prospective study had one RBA and two LBA, and in four patients the RBA was divided at both sides of the esophagus and preserved one of the LBA. Lymphadenectomy was performed of stations 4R, 4L, 2R and 2L, with a median of 11 resected lymph nodes. Both recurrent laryngeal nerves were identified in four patients. In three patients, only the left recurrent nerve could be identified. Two patients showed palsy of the left recurrent laryngeal nerve, and one showed neuropraxia of the left vocal cord.ConclusionsKnowledge of the surgical anatomy of the upper mediastinum and its anatomical variations is important for standardization of an adequate esophageal resection and paratracheal lymphadenectomy with preservation of any vascularization of the trachea, bronchi and the recurrent laryngeal nerves.
Highlights
During esophageal dissection and lymphadenectomy of the upper mediastinum by thoracoscopy in prone position, we observed a complex anatomy in which we had to resect the esophagus, dissect vessels and nerves, and take down some of these in order to perform a complete lymphadenectomy
As the supracarinal esophagus is vascularized on both sides, it is of utmost importance to know the variable anatomy when performing an esophageal resection up to the thoracic apex and for doing a complete lymphadenectomy on both sides of the trachea and of both recurrent laryngeal nerves [2,3,4,5]
Indication for total mediastinal LN included all patients with squamous cell cancer (SCC) and esophageal cancer in distal locations with suspected involvement of the lymph nodes in the high mediastinum, as determined by PET-CT scan
Summary
In this retrospective and prospective study of minimally invasive esophagectomy (MIE) in prone position, our aim was to describe the surgical anatomy of the upper mediastinum, and the landmarks and structures that have to be divided, in order to perform an adequate esophagectomy and lymphadenectomy
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