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Shiozaki et al. Mini-invasive Surg 2020;4:50 Mini-invasive Surgery
DOI: 10.20517/2574-1225.2020.31

Technical Note Open Access

Advances and understanding pitfalls of
laparoscopic transhiatal esophagectomy with en

bloc mediastinal lymph node dissection

Atsushi Shiozaki, Hitoshi Fujiwara, Hirotaka Konishi, Hiroki Shimizu, Michihiro Kudou, Tomohiro Arita,
Toshiyuki Kosuga, Ryo Morimura, Yoshiaki Kuriu, Hisashi Ikoma, Takeshi Kubota, Kazuma Okamoto,
Eigo Otsuji

Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan.
Correspondence to: Dr. Atsushi Shiozaki, Assistant Professor, Division of Digestive Surgery, Department of Surgery, Kyoto
Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto 602-8566, Japan. E-mail: shiozaki@koto.kpu-m.ac.jp
How to cite this article: Shiozaki A, Fujiwara H, Konishi H, Shimizu H, Kudou M, Arita T, Kosuga T, Morimura R, Kuriu Y, Ikoma
H, Kubota T, Okamoto K, Otsuji E. Advances and understanding pitfalls of laparoscopic transhiatal esophagectomy with en bloc
mediastinal lymph node dissection. Mini-invasive Surg 2020;4:50. http://dx.doi.org/10.20517/2574-1225.2020.31
Received: 16 Mar 2020 First Decision: 10 Jun 2020 Revised: 1 Jul 2020 Accepted: 22 Jul 2020 Published: 15 Aug 2020

Academic Editor: Itasu Ninomiya Copy Editor: Cai-Hong Wang Production Editor: Jing Yu

Abstract
We began performing mediastinal lymph node dissection using the laparoscopic transhiatal approach in 2009.
Following the initiation of the single-port mediastinoscopic cervical approach in 2014, we developed a technique
for transmediastinal radical esophagectomy without a thoracic approach. We herein describe our surgical
procedures for en bloc mediastinal lymph node dissection by the laparoscopic transhiatal approach with a focus
on pitfalls. We opened the esophageal hiatus and the working space was secured using long retractors. During
division of the right crus of the diaphragm, we made efforts to avoid damaging the left hepatic vein and inferior
vena cava. Dissection of the posterior plane of the pericardium was extended to the cranial side, and the bilateral
inferior pulmonary veins were identified. To avoid misorientation, the posterior plane was initially extended along
the long axis of the esophagus. The anterior and posterior sides of the posterior mediastinal lymph nodes were
then both dissected. These lymph nodes were lifted in a sheet-like form and then cut along the borderline of the
left mediastinal pleura. The right side of the mediastinal lymph nodes was then dissected. To avoid damaging
the arch of the azygos vein, it was identified at the dorsal side of the right main bronchus prior to lymph node
dissection. This procedure decreased the total operative time, total operative bleeding, and postoperative
respiratory complications without reducing the quality of lymphadenectomy. In conclusion, the procedure
described herein resulted in a good surgical view and safe en bloc mediastinal lymph node dissection. A detailed
understanding of mediastinal 3D anatomy and specific pitfalls is crucial for the successful use of this approach.

© The Author(s) 2020. Open Access This article is licensed under a Creative Commons Attribution 4.0
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