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Page 2 of 10 Tokairin et al. Mini-invasive Surg 2020;4:32 I http://dx.doi.org/10.20517/2574-1225.2020.23

INTRODUCTION
Conventional radical esophagectomy through right thoracotomy is one of the most invasive procedures. It
is important to reduce the invasiveness of this procedure.

Conventional radical esophagectomy was previously performed for the treatment of mucosal esophageal
cancers for patients diagnosed with not only advanced esophageal cancer but also T1a N0 M0 cStage I
[1]
according to the Union for International Cancer Control TNM Classification (eighth edition) ; however,
endoscopic submucosal dissection has come to be performed for patients with T1a N0 M0 cStage I as
[2]
minimally invasive treatment and the methods have been well established .

On the other hand, the esophagectomy with dissection of the mediastinal and abdominal lymph nodes is
needed for the treatment of thoracic esophageal cancer with invasion of the submucosal layer or deeper
layers. For the abovementioned reason, hybrid surgery consisting of a two-field abdominal-thoracic
[3]
operation (called the Ivor-Lewis procedure) was developed . In Western countries, abdominal esophageal
cancer and esophagogastric junctional cancers are well observed and later histological types are frequently
diagnosed as “adenocarcinoma”. Thus, this procedure is considered reasonable because esophageal cancers
at these locations are rarely associated with upper mediastinal and cervical lymph node metastasis.
Esophageal cancers in the thoracic esophagus are frequently associated with upper mediastinal and cervical
lymph node metastasis. Thus, this procedure is not suitable for these esophageal cancers. To resolve this
[4]
problem, McKeown developed total esophagectomy with three-field lymph node dissection .

Currently, radical esophagectomy through right thoracotomy has changed to esophagectomy via a
thoracoscopic or laparoscopic approach, including robot assisted surgery, which reduces the invasiveness
of the procedure by decreasing the destruction of thoracic and abdominal walls [5-11] . However, this method
mandates the use of one-lung ventilation, some destruction of the thoracic wall, or prone positioning.

Conventional transhiatal esophagectomy has been performed and mediastinoscopic esophagectomy has
been developed. These procedures are also recognized as types of minimally invasive esophagectomy (MIE) [12-14] .
However, due to the blind maneuvering in the upper and middle mediastinum that is necessary in this
procedure and the difficulty of systematic lymph node dissection, it is usually only applied in limited cases,
such as cases of esophagogastric junction cancer, very early-stage cancers, or some cases of advanced
[12]
thoracic esophageal cancer for the purpose of palliative resection .

Recently, we developed and reported the performance of “mediastinoscopic esophagectomy with lymph
node dissection (MELD)” under pneumomediastinum using a bilateral transcervical and transhiatal
approach, as a method of radical esophagectomy [15-18] . This procedure achieves curative radical
esophagectomy with minimal invasiveness. Upper mediastinal lymph node dissection has been performed
using bilateral open cervical surgery and a left transcervical and transhiatal pneumomediastinal approach
in some institutions [19,20] . However, in the results of our clinical trial, the right recurrent nerve lymph nodes,
the upper thoracic paraesophageal lymph nodes, and the subaortic arch to the left tracheobronchial lymph
nodes could not be completely dissected using the left transcervical approach alone [17,18] . We are therefore
of the opinion that a right cervical pneumomediastinal approach is necessary to achieve the complete
dissection of these lymph nodes. We herein describe the surgical technique using a bilateral (especially
right cervico-pneumomediastinal) approach.

TECHNIQUE
In the MELD procedure, the right cervical approach is performed first, followed by the left cervical
approach and laparoscopic-transhiatal approach.